Health Assessment Learning Objectives

ch. 33 describe the importance of effective family communication

clear verbal, nonverbal, and circular communications increase open and effective family communication and help to build up family members

ch. 24 describe the structure and the function of the musculoskeletal system

the musculoskeletal system consists of bones, muscles, and joints and functions in providing structure and movement for body parts

ch. 8 discuss the assessment of pain as a fifth vital sign

when pain is present, identify the location, intensity, quality, duration, and any alleviating or aggravating factors to the client

ch. 9 differentiate between the etiology of acute and chronic pain

- acute pain is usually associated with a recent injury - chronic pain is usually associated with a specific cause or injury and is described as a constant pain that persists for more than six months

ch. 25 describe the structure and the function of the central and peripheral nervous systems

- the CNS and PNS are responsible for coordinating and regulating all body functions - the central nervous systems consists of the brain, spinal cord, meninges, three layers of connective tissue, subarachnoid space, cerebrospinal fluid, and neurons - the peripheral nervous system consists of the 12 pairs of cranial nerves, 31 pairs of spinal nerves, somatic fibers, and autonomic fibers

ch. 1 list and describe the steps of the nursing process, explaining how some steps overlap and may have to be repeated many times when caring for a client

- assessment: collecting subjective and objective data - diagnosis: analyzing subjective and objective data to make a professional nursing judgment, diagnosis, collaborative problem, or referral - plan: determining outcome criteria and developing a plan - implementation: carrying out the plan - evaluation: assessing whether outcome criteria have been met and revising the plan as necessary

ch. 1 compare and contrast the four basic types of nursing assessment: initial comprehensive, ongoing/partial, focused/problem oriented, emergency

- initial comprehensive involves collection of subjective data about the client's perception of their health, past history, family history, and health practices - ongoing/partial consists of data collection that occurs after the comprehensive database is established - focused/problem oriented is performed when a comprehensive database exists for a client who comes with a specific health concern - emergency is a very rapid assessment performed in life-threatening situations

ch. 20 differentiate between general routine screening versus skills needed for focused or specialty assessment of the breasts and axillary lymph nodes

- the general routine screening of the breasts and axillary lymph nodes includes the inspection of size and symmetry, color and texture, superficial venous patterns, areolas and nipples, retraction or dimpling, palpation of texture, elasticity, tenderness, temperature, and asking the client if they know how to perform a BSE - the specialty assessment of the thorax and lungs consists of the palpation of nipples for discharge, breasts for masses, mastectomy or lumpectomy sites, axillae, and inspection of axillae

ch. 13 discuss the role of the essential nutrients in healthy nutrition including carbohydrates, proteins, fats, vitamins, minerals, and water

- carbohydrates: simple carbs are sugar with a simple structure that quickly raises blood glucose levels and can be converted into energy quickly, complex carbs are composed of double or multiple sugar units and can also be used as an energy source, stored in the liver and muscle, help to burn fats more efficiently, diet should consist of 45-65% carbohydrates - proteins are essential for normal growth and development, stored in muscle, skin, bone, blood, cartilage, and lymph tissue, can be broken down for energy but as well as carbs, provide structure to and regulate the body's cells, tissues, and organs, provide transport and storage of atoms and small molecules within cells and throughout the body, can be obtained from plant and animal sources, diet should consist of 56 g for men and 46 g for women - fats are an important part of a well-balanced diet, stored in adipose cells and are classified as triglycerides, ingested fats are saturated (originating from animal sources and solid at room temp) or unsaturated (originating from plant sources and liquid at room temp), provide concentrated energy, aid in absorption of fat-soluble vitamins, supply essential fatty acids for healthy skin, insulate skin and nerve fibers, protect internal organs, and lubricate skin to slow water loss - vitamins are required for energy to be released from carbs, proteins, and fats, necessary for the formation of red blood cells, hormones, genetic material, and a functioning nervous system, categorized as either fat or water soluble, can be reduced or destroyed by overcooking, diet changes based on the specific vitamin, age, lifestyle, and health - minerals promote growth and maintain health, can be found in all body fluids and tissues, best sources are in unrefined and unprocessed foods, categorized as either major (calcium, potassium, and sodium) or trace minerals (fluoride, iron, and zinc), diet changes based on the specific mineral, age, lifestyle, and health - water one of our most basic nutritional needs, accounts for 50-75% body weight, serves as a building block of cells, insulates, regulates internal temperature, metabolizes proteins and carbs, lubricates joints, insulates the brain, spinal cord, internal organs, and a fetus, flushes out toxins and wastes, diet should consist of four L for men and two L for women

ch. 2 explain how a nurse would use the COLDSPA mnemonic to analyze a client's symptoms

- character: describe the sign or symptom - onset: when it began - location: where the pain is and radiates to - duration: how long it lasts and recurs - severity: intensity of the pain - pattern: what makes it better or worse - associated factors: other symptoms that occur with it

ch. 9 perform a physical assessment of a client experiencing pain

- choose an assessment tool reliable and valid to the client's culture - explain to the client the purpose of rating the intensity of pain - ensure their privacy and confidentiality - respect the client's behavior toward pain and terms used to express it - understand that different cultures express pain differently - observe posture and facial expressions - assess face, legs, activity, cry, and consolability - inspect joints and muscles - observe skin for scars, lesions, rashes, changes, or discoloration - measure heart rate, respiratory rate, and blood pressure - assess nonverbal client for pain

ch. 32 differentiate between common variations and the atypical presentation of disease and illness seen in the older adult

- common variations of diseases in older adults include skin impairment, poor nutrition, incontinence, cognitive impairment, evidence of falls or functional decline, and sleep disturbances - atypical presentations of illnesses in older adults consist of immobility, pressure ulcers, urinary tract infections, delirium, malnutrition, eating and feeding problems, dizziness, syncope, weight loss, and self-neglect

ch. 33 use Bowen's theory to determine the level of self-differentiation of a family and its members and to detect triangle within a family

- differentiation of self is assessed in relation to the boundaries of the subsystems in the structure of the family based on the balance of emotional and intellectual levels of function - triangles are discussed in relation to subsystems of family structure that are described as a relational pattern or emotional configuration that exists among one or two family members and another person, object, or issue

ch. 3 describe the purpose of direct, indirect, and blunt percussion

- direct percussion is the direct tapping of a body part with one or two fingertips to elicit possible tenderness - indirect percussion is the tapping done to produce a sound or tone that varies with the density of underlying structures (as density increases, the sound of the tone becomes quieter and vice versa) - blunt percussion is the placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand to detect tenderness over organs

ch. 14 teach a client to perform a self-assessment of the skin, hair, and nails

- examine head and face using one or both mirrors and a blow dryer to inspect the scalp - check hands, elbows, arms, and underarms in a full-length mirror - focus on the neck, chest, torso, and under the breasts - inspect back of neck, shoulders, upper arms, back, buttocks, and legs with a hand mirror - check legs, feet, soles, heels, nails, and genitals sitting down

ch. 33 discuss theoretical concepts of family function

- family systems theory: a system is composed of subsystems interconnected to the whole system and to each other by means of an integrated and dynamic self-regulating feedback mechanism - Bowen's family systems theory: familial emotional and interaction patterns are reflected in eight interwoven concepts, especially differentiation of self and triangles - communication theory: concerns the sending and receiving of both verbal and nonverbal messages with how individuals interact with one another

ch. 17 describe the functions and structures of the ears

- functions of the ears include hearing and equilibrium - the external ear is composed of the auricle (pinna) and external auditory canal, auricle is the portion of the external ear that is visible without any tools and conducts sounds waves, and external auditory canal is S shaped and secretes cerumen to keep the tympanic membrane soft - the middle ear contains the tympanic cavity, tympanic membrane (eardrum), malleus, incus, stapes, and eustachian tube, tympanic cavity is a small air-filled chamber that separates the external and inner ear, tympanic membrane is translucent and serves as a partition across the inner end of the auditory canal, malleus, incus, and stapes are the three auditory ossicles that transmit sound waves from the eardrum to the inner ear, and eustachian tube connects the middle ear to the nasopharynx and equalizes air pressure - the internal ear is fluid filled and made up of the bony labyrinth and inner membranous labyrinth, bony labyrinth consists of the cochlea, vestibule, and semicircular canals, sensory receptors sense position and head movements and maintain static and dynamic equilibrium, and vestibular nerve connects with the cochlear nerve to form the VIII cranial nerve (vestibulocochlear nerve)

ch. 1 differentiate between a holistic nursing assessment and a physical medical assessment

- holistic collects holistic subjective and objective data to determine overall level of functioning in order to make nursing diagnosis - physical medical focuses on the physiological status of the patient

ch. 3 demonstrate correct inspection, palpation, percussion, and auscultation examination techniques

- inspection: make sure the room is a comfortable temperature, use good lighting, look and observe before touching, completely expose the body part, compare appearance of symmetrical parts, and note color, patterns, size, location, consistency, symmetry, movement, behavior, odors, and sounds - palpation: feel texture, temperature, moisture, mobility, consistency, strength of pulse, size, shape, and degree of tenderness - percussion: listen when eliciting pain, determining density, detecting abnormal masses, eliciting reflexes, and determining location, size, and shape - auscultation: eliminate distracting noises, expose the body part, use the diaphragm to listen for high pitched sounds (heart, breath, and bowel sounds), and use the bell to listen for low pitched sounds (abnormal heart and bruit sounds)

ch. 19 identify the thoracic landmarks in relation to the underlying thoracic structures

- landmarks of the anterior thoracic cage are the suprasternal notch, clavicle, manubrium of sternum, manubriosternal angle, body of sternum, xiphoid process, costal cartilage, intercostal spaces, dome of the diaphragm, costal angle, costal margin, and costochondral junction - landmarks of the posterior thoracic cage are the vertebral prominens, clavicle, acromion process, spinous process of T3, scapula, and lower tip of scapula

ch. 3 differentiate between light, moderate, deep, and bimanual palpation

- light palpation feels for pulses, tenderness, surface skin texture, temperature, and moisture - moderate palpation feels for easily palpable body organs and masses - deep palpation feels for very deep organs or structures covered by thick muscle - bimanual palpation feels for structures on both sides of the body

ch. 9 interview a client for their subjective experience of pain

- maintain a quiet and calm environment - maintain the client's privacy and ensure confidentiality - ask open-ended questions - listen carefully to their verbal descriptions - watch for the client's facial expressions - do not put words in their mouth - ask the client about past experiences with pain - believe their expression of pain - use the COLDSPA method (character, onset, location, duration, severity, pattern, and associated factors), ask about personal and family health history, and determine lifestyle and health practices

ch. 31 differentiate between normal and abnormal findings of children and adolescents

- normal findings of children and adolescents include appearance of stated age, clean, well nourished, no unusual body odor, alert, active, responds appropriately to situation, maintains eye contact, appropriately interactive, seeks comfort from parents, appears happy, attentive, speech is appropriate, follows commands, reasonably cooperative, lordotic when a toddler, slightly bowlegged when a preschooler, straight and well-balanced when older, meets normal parameters, temperature of 98.6°F, pulse rate of 80-150 bpm from 3 months to 2 years, 70-110 from 2 to 10 years, and 55-90 from 10 years to adult, respiratory rate of 30-53 breaths per minute for an infant, 22-37 for a toddler, 20-28 for a preschooler, 18-25 for a school-age child, and 12-20 for an adolescent, systolic BP of age in years + 90 for 1-7 years and (2 x age) + 90 for 7-18 years, diastolic BP of 53-66 for 1-6 years and age + 52 for 6-18 years, normal growth in charts, appropriate skin color, no strong odor, no lesions, soft, warm, and slightly moist skin, lustrous and elastic hair, fine and downy hair across the body, clean and groomed nails, normocephalic and symmetric head, full ROM, proportionate and symmetric face, equal and bilateral movements, normal sized parotid gland, palpable isthmus, midline trachea, nonpalpable lymph nodes, pink and moist lips, tongue, and buccal mucosa, deciduous teeth, permanent teeth by 6, present tonsils, midline nose, straight septum, no discharge or tenderness, pink turbinates, no tender sinuses, no swelling, discharge, or lesions of eyelids, clear sclera and conjunctiva, equal, round, reactive to light, and accomodating pupils, symmetric eyebrows, evenly distributed eyelashes, visual acuity of 20/200 for 1 year, 20/70 for 2 years, 20/30 for 5 years, and 20/20 for 6 years, color differentiation, focused eyes, symmetric light reflection on both pupils, present red reflex, no excessive cerumen, discharge, lesions, excoriations, or foreign bodies in ears, pearly gray and mobile tympanic membrane, answers whispered questions, normal audiometry results, thoracic diameter of 1:2 or 5:7, respirations of 20-28 breaths per minute for 2-10 years and 12-20 for 10-18 years, hyperresonance in lungs, louder and harsher breath sounds, flat and symmetric breasts, apical pulse at 4th intercostal space, innocent murmurs, short heart beat duration, low-pitched, prominent abdomen, pink and no herniation of umbilicus, normal bowel sounds, soft abdomen, palpable liver, palpable spleen tip, palpable kidney tips, palpable bladder, normal sized penis, retractable penis, scrotum free of lesions, palpable testes in scrotum, smooth and mobile testes, no inguina hernias, pink and moist labia majora and minora, full labia, thick hymen, no discahrge from vagina or urinary meatus, visible and moist anal opening, no hemorrhoids or lesions, smooth perianal skin, nonpalpable prostate gland, symmetric and normally positioned feet and legs, warm and mobile extremities, strong and bilateral pulses, metatarsus adductus, tibial torsion, lumbar curve, wide-based gait, genu varum, genu valgum, full ROM, no swelling or redness, adequate and bilateral muscle strength, increased independence, easily understood speech, Babinski response normal in younger than 2, absent triceps reflex until 6, balanced, coordinated, sensitivity to touch, two-point discrimination, appropriate gross and fine motor skills, and disappeared soft signs - abnormal findings of children and adolescents consist of lack of eye contact, facies of fear, anxiety, anger, allergies, acute illness, pain, mental deficiency, or respiratory distress, irregular posture or movement, poor hygiene, abnormal behavior, abnormal development, lags in earlier stages, hypothermia, hyperthermia, irregular pulse rate, slow or fast respiratory rate, systolic and diastolic BP above 95th percentile, significant deviation from normal in the growth charts, jaundice, cyanosis, urine odor, ecchymoses, petechiae, more than six café-au-lait spots, excessive dryness, flaking or scaling, dirty and matted hair, dull and brittle hair, ticks or lice, alopecia, trichotillomania, chemotherapy, tufts of hair over spine, coarse body hair, pubic hair in younger than 8, nailbed hemorrhage, short and ragged nails, clubbing, macerated thumb tip, paronychia, hydrocephalus, presence of third fontanelle, craniotabes, hyperextension, limited ROM, unusual proportions, unequal movements, enlarged parotid gland, abnormal facies, crease across nose, shiners, mouth agape, enlarged or palpable thyroid, short and webbed neck, distended neck veins, deviated trachea, enlarged and firm lymph nodes, dry lips, stomatitis, dental caries, enamel erosion, tosillar or pharyngeal inflammation, deviated septum, foul discharge, pale nasal mucosa, polyps, tender sinuses, hypertelorism, eyelid inflammation, ptosis, stye, cyst, sunken orbital area, periorbital edema, osteogenesis imperfecta, brushfield spots, sluggish pupils, miosis, mydriasis, sparseness of eyebrows or eyelashes, corneal abrasions, one-line difference, visual impairment, unequal alignment of light on pupils, absence of red reflex, low-set ears, abnormal shape of ears, presence of foreign bodies, cerumen impaction, purulent or serous discharge, perforated tympanic membrane, failure to answer whispered questions, unnormal audiometry results, abnormally shaped thorax, retractions and grunting, dull tone over lungs, diminished breath sounds, stridor, expiratory wheezes, rhonchi and rales, mastitis, gynecomastia, precocious puberty, thelarche, systolic heave, cardiomyopathy, pneumothorax, or diaphragmatic hernias, murmurs, extra heart sounds, scaphoid abdomen, inflammation and discharge of umbilicus, diastasis recti, bulge at umbilicus, marked peristaltic waves, rigid abdomen, masses or tenderness, enlarged liver with firm edges, enlarged spleen, enlarged kidneys, enlarged bladder, unretractable foreskin, paraphimosis, hypospadias, absent testicles, atrophic scrotum, cryptorchidism, hydroceles, bulges or hernias in inguinal area, partial or complete labia minora adhesions, imperforate hymen, discharge, redness, or edema of vagina or urinary meatus, imperforate anus, hemorrhoids, bleeding and pain, pustules, lacerations, purulent discharge, palpable masses, short and broad extremities, polydactyly, syndactyly, fixed-position deformities, metatarsus varus, talipes varus, talipes equinovarus, neurovascular deficit, kyphosis, scoliosis, asymmetric extremities, congenital hip dysplasia, synovitis, Legg-Calvé-Perthes disease, limited ROM, swelling and redness, inadequate and asymmetric muscle strength, altered level of consciousness, maladaptation, slurring, alteration in cranial nerve function, absence of reflexes, sustained ankle clonus, unstable gait, lack of coordination, positive Romberg test, absent or decreased sensitivity to touch, no two-point discrimination, inappropriate gross and fine motor skills, no development of hand preference, short attention span, poor coordination of position, hypoactivity, impulsiveness, labile emotions, distractability, language and articulation problems, and learning issues

ch. 23 differentiate between normal and abnormal findings of the abdomen

- normal findings of the abdomen include paler abdominal skin, scattered fine veins, pink or blue striae, pale and smooth scars, no lesions or rashes, umbilicus is midline, abdomen is inverted, flat, rounded, or scaphoid, symmetric, no bulging, abdominal respiratory movement, slight pulsation of aorta, no peristaltic waves, intermittent and soft clicks and gurgles, no bruits, no venous hum, generalized tympany over abdomen, dullness over liver and spleen, nontender and soft abdomen, mild tenderness over xiphoid, aorta, cecum, sigmoid colon, and ovaries, not palpable liver, not palpable or tender bladder, constant tympany and dullness, no fluid waves, no rebound tenderness, no rebound pain, no abdominal pain, and no increase in pain - abnormal findings of the abdomen consist of purple discoloration, jaundice, ascites, redness, bruises, local discoloration, dilated veins and arteries, dark blue striae, non-healing wounds, inflammation, changes in moles, Cullen sign, umbilicus is deviated, everted umbilicus, protuberant or distended abdomen, asymmetric, hernia, diminished abdominal respiration, vigorous and wide pulsations, increased peristaltic waves, hyperactive bowel sounds, absent bowel sounds, systolic and diastolic bruits, venous hum, accentuated tympany or hyperresonance, involuntary reflex guarding, rigid abdomen, severe tenderness or pain, hard and firm liver, nodular liver, distended and tender bladder, ascites, movement of fluid wave, sharp and stabbing pain, referred pain, abdominal pain, and increase in pain

ch. 20 differentiate between normal and abnormal findings of breasts and axillary lymph nodes

- normal findings of the breasts and axillary lymph nodes include round and pendulous breasts, smooth texture, no edema, linear stretch marks, horizontal or vertical veins, dark pink to dark brown areolas, equal and everted nipples, breasts rising symmetrically, hanging freely, firm and elastic tissue, normal body temperature, no masses, rubbery and mobile masses, milky discharge, no lesions or lumps, no tenderness, no rash or infection, and no enlarged lymph nodes - abnormal findings of the breasts and axillary lymph nodes consist of recent increase in the size of one breast, redness, peau d'orange, prominent venous pattern, redness, scaliness, crustiness, retracted nipple, spontaneous discharge, dimpling, restricted movement, thickening of tissues, painful and tender breasts, hard and immobile masses, fibroadenomas, milk cysts, lipomas, intraductal papilloma, nipple discharge, inflammation, and enlarged lymph nodes

ch. 17 differentiate between normal and abnormal findings of the ears and hearing

- normal findings of the ears and hearing include ears being equal in size, smooth skin with no lesions, lumps, or nodules, color is consistent with facial color, Darwin's tubercle may or may not be present, auricle, tragus, and mastoid process are not tender, small amount of odorless cerumen, cerumen colors (yellow, orange, red, brown, gray, or black) and consistencies (dry, flaky, soft, moist, or hard), smooth and pink canal walls, translucent tympanic membrane, no bulging or retraction, healthy membrane flutters when bulb is inflated, able to pass the whisper test, vibrations are heard in both ears, air conduction sound is heard longer than bone conduction sound, and client maintains position for 20 seconds with minimal swaying - abnormal findings of the ears and hearing consist of ears smaller than four cm or larger than 10 cm, low-set ears, not fully developed external ears (microtia), excessive enlargement of ears (macrotia), enlarged auricular lymph nodes, tophi (nodules containing uric acid), ulcerated and bleeding nodules, redness, swelling, scaling, itching, pale blue color, painful auricle or tragus, tenderness around ear, sticky and yellow discharge, blood and purulent discharge, blood or watery drainage, impacted cerumen, foreign bodies present, reddened and swollen canals, exostoses (nonmalignant swellings), polyps, red and bulging eardrum, yellow and bulging membrane, blood behind the eardrum, white scarring from infection, perforations, prominent or absent landmarks, unable to repeat the whisper test after two tries, reports conductive hearing loss (hears sound in the poor ear), reports sensorineural hearing loss (hears sound only in the good ear), bone conduction sound is heard for the same time or longer than air conduction sound, and client moves feet to prevent fall or sways from loss of balance

ch. 16 differentiate between normal and abnormal findings of the eye and vision

- normal findings of the eyes and vision include 20/20 distant visual acuity with or without corrective lenses, 14/14 near visual acuity, visual field degrees of 70° for inferior, 50° for superior, 90° for temporal, and 60° for nasal, reflection of light on corneas is in the same spot, uncovered eye remains fixed ahead, smooth and symmetric eye movement, upper lid should be between upper margin of the iris and pupil, lower lid should rest on the lower border of the iris, lids close easily and meet completely, eyelashes are evenly distributed, eyelids are not red, swollen, or with lesions, symmetrically aligned eyeballs, clear, moist, and smooth bulbar conjunctiva, white sclera, palpebral conjunctiva are clear and free of swelling and lesions, no sign of foreign bodies or trauma, no drainage upon palpation, transparent cornea, lens free of opacities, round, flat, and evenly colored irises, round and bordered pupils, constriction of pupils to light, convergence of eyes to near objects, red reflex visible through ophthalmoscope, round and bordered optic disc, physiologic cup (where the optic nerve enters the eyeball) appears depressed and lighter, four sets of arterioles and venules are seen in the optic disc, bright red arterioles, darker and larger venules, background is consistent in red-orange color, macula is the darker area with a star-like light reflex called the fovea, and anterior chamber is transparent - abnormal findings of the eyes and vision consist of near sightedness (myopia), legal blindness with 20/200 visual acuity, far sightedness (presbyopia), delayed or absent perception of peripheral vision, asymmetric position of the light reflex, uncovered eye moving to establish focus, covered eye is uncovered and moves to re-establish focus, drooping of the upper lid (ptosis), retracted lid margins, failure of lids to close completely, inverted lower lid (entropion), everted lower lid (ectropion), redness and crusting along lid margins, protrusion of eyeballs and retraction of eyelids (exophthalmos), generalized redness of the conjunctiva, areas of dryness, inflammation of the sclera, yellow sclera, bright red spots on sclera, cyanosis of lower lid, irritation due to foreign body or lesion, swelling of lacrimal gland, drainage from puncta on palpation, areas of roughness or dryness on cornea, irregularly shaped irises, different sized pupils, monocular blindness when neither pupil constricts or both do, eyes do not converge to near object, cataracts form black spots on the red reflex, swelling of the optic disc (papilledema), glaucoma interferes with the blood supply to optic structures, optic atrophy causes white in color and lack of disc vessels, constricted arterioles, dilated veins, absence of major vessels, hypertension, thick and opaque arteriole walls, arterial nicking or tapering, patches from diabetes or hypertension, hemorrhages, macular degeneraiton, injury causes red blood cells to collect (hyphemia), and inflammatory response causes white blood cells to accumulate (hypopyon)

ch. 27 differentiate between normal and abnormal findings of female genitalia, anus, and rectum

- normal findings of the female genitalia, anus, and rectum include pubic hair in a triangular pattern, no infestation, no enlargement of lymph nodes, equal size of labia majora, smooth perineum, shriveled labia, symmetric labia minora, no discharge, soft and nontender urethral meatus, moist vaginal opening, ability to squeeze vaginal opening, pink and even cervix, small and round cervix, clear and white secretions, moist and smooth vagina, pink and nontender vaginal wall, firm and soft cervix, round and firm fundus, freely moving uterus, almond-shaped ovaries, smooth and mobile ovaries, thin and movable rectovaginal septum, firm and round uterine wall, moist and tightly closed anal opening, smooth and hairless sacrococcygeal area, sphincter relaxes, examination finger can enter, ability to close sphincter, soft and nontender anus, smooth rectal mucosa, and semi-solid and brown stool - abnormal findings of the female genitalia, anus, and rectum consist of removal or trimming of hair, infestation, enlargement of lymph nodes, unequal size of labia majora, lesions on perineum, excoriation and swelling, asymmetric labia minora, abscess, bulging in the vaginal opening, discharge, hard and tender urethral meatus, thinner and dryer vagina, absent or decreased ability to squeeze vaginal opening, cystocele, uterine prolapse, cyanosis, redness, asymmetric cervix, yellow and odorous secretions, white patches and strawberry spots, altered pH, hard and immobile cervix, myomas, endometriosis, enlarged uterus, immobile and enlarged ovaries, thickened structures, swollen and bleeding masses, anorectal fistula, thickening of epithelium, dry and loose anal opening, hemorrhoids, anal fissure, dimpled areas, pilonidal cyst, sphincter tightens, examination finger cannot enter, inability to close sphincter, hard and tender anus, rough rectal mucosa, liquidy and discolored stool, and blood in stool

ch. 8 differentiate between normal and abnormal findings in the general survey and vital signs

- normal findings of the general survey and vital signs include appropriate levels of fat, muscle, body proportions, sexual development, chronological age, skin color, straight posture, 36.7-38.3°C or 98.0-100.9°F, 60-100 beats per minute, regular intervals between beats, 12-20 breaths per minutes, regular breathing rhythm, systolic pressure is less than 120 mm Hg, diastolic pressure is less than 80 mm Hg, and the client seems comfortable and relaxed - abnormal findings of the general survey and vital signs consist of high levels of fat, low of muscle, body disproportions, slow sexual development, look too old for their age, uneven skin color, bad posture, below 36.7°C or 98.0°F, above 38.3°C or 100.9°F, less than 60 or more than 100 beats per minute, irregular intervals between beats, less than 12 or more than 20 breaths per minute, irregular breathing rhythm, systolic pressure is greater than 120 mm Hg, diastolic pressure is greater than 80 mm Hg, and the client seems uncomfortable and in pain

ch. 15 differentiate between normal and abnormal objective and subjective findings related to the head and neck

- normal findings of the head and neck include symmetry, round, erect, and midline head positioning, no visible lesions, hard and smooth head, oval and elongated face, temporal artery is elastic and not tender, no swelling, tenderness, or crepitation of the TMJ, symmetric neck with no bulges, thyroid and cricoid cartilage move upward when swallowing, C7 is visible, smooth neck movement with 45° flexion, 55° extension, 40° abduction, and 70° rotation, trachea and landmarks are midline, no bruits auscultated, and no swelling, enlargement, or tenderness of lymph nodes - abnormal findings of the head and neck consist of a small head (microcephaly), large skull and facial bones (acromegaly), neurologic disorders that cause jerking movements, lesions or lumps on the head, asymmetry, drooping, weakness, or paralysis on one side of the face, thick and hard temporal artery, limited TMJ range of motion, swelling or crepitation of the TMJ, swelling or enlarged masses on the neck, asymmetric movement of the thyroid gland, prominence other than the C7, muscle spasms, inflammation, or cervical arthritis, stiff neck, trachea is pushed to the side, landmarks deviate from the midline, goiter may be present in the thyroid, coarse tissue or irregular consistency, soft blowing sounds auscultated over the thyroid lobes, and swelling, enlargement, and tenderness of lymph nodes

ch. 21 differentiate between normal and abnormal findings of the heart and neck vessels

- normal findings of the heart and neck vessels include no visible jugular venous pulse, no blowing or swishing of carotid arteries, bilaterally strong pulses, visible apical impulse, apical amplitude is small and brief, no pulsations or vibrations are palpated, rate should be 60-100 bpm, regular rhythm, radial and apical pulse rates are identical, S1 corresponds with each carotid pulsation, S2 immediately follows S1, no extra heart sounds, no murmurs, and S1 and S2 heart sounds are present in other positions - abnormal findings of the heart and neck vessels consist of fully distended jugular veins, bruits, blowing or swishing sounds of the carotid arteries, pulse inequality, weak or absent pulses, pulsations other than the apical pulsation, not palpable apical impulse, thrills, bradycardia (less than 60 bpm), tachycardia (more than 100 bpm), irregular rhythm, pulse deficit (difference between apical and radial pulses), accentuated, diminished, or split S1, wide, fixed, or reversed S2, ejection sounds or clicks, pathologic S3, pathologic S4, quadruple rhythm, midsystolic, pansystolic, or diastolic murmurs, and extra heart sounds or murmurs are present in other positions

ch. 26 differentiate between normal and abnormal findings of male genitalia, anus, rectum, and prostate

- normal findings of the male genitalia, anus, rectum, and prostate include coarse pubic hair, no excoriation, erythema, or infestation, wrinkled and hairless penis, no rashes, lesions, or lumps, soft and flaccid penis, intact and uniform foreskin, rounded and broad glans, smooth glans, foreskin retracts easily, smegma accumulation, slit-like urinary meatus, no discharge from meatus, scrotal sac hangs below penis, left side lower than right, thin and rugated scrotal skin, sebaceous cysts, ovoid and symmetric testes, firm, rubbery, and mobile testes, nontender and smooth epididymis, uniform spermatic cord and vas deferens, nontender and smooth cord, scrotal contents non-transilluminable, free from bulges, no enlargement, moist and tightly closed anal opening, no redness or rashes, no hair or ulcers, sphincter relaxes, examination finger can enter, closable sphincter, smooth and nontender anus, soft and smooth rectal mucosa, rubbery and nontender prostate, and stool is semi-solid and brown - abnormal findings of the male genitalia, anus, rectum, and prostate consist of absence or scarcity of pubic hair, lice or nit infestation, rashes, lesions, or lumps, tenderness, inflammation or infection, discoloration, chancres from syphilis, genital warts, or herpes, phimosis, paraphimosis, hypospadias, epispadias, yellow or white discharge, enlarged scrotal sac, hydrocele, hematocele, hernia, cancer, varicocele, absence of a testis, cryptorchidism, painless nodules, palpable and tortuous veins, cysts, solid masses with blood, bulges, enlargement, dry and loose anal opening, redness or rashes, hair or ulcers, sphincter tightens, examination finger cannot enter, poor sphincter tone, tightened sphincter tone, polyps, hardness, fixed nodules, rectal shelf, liquidy and discolored stool, and blood in the stool

ch. 16 discuss risk factors for development of cataracts and ways to reduce risk factors

- risk factors for cataracts include increasing age, diabetes, excessive amounts of alcohol, exposure to sunlight and ionizing radiation, family history of cataracts, high blood pressure, obesity, previous eye injury or inflammation, previous eye surgeries, prolonged use of corticosteroids, and smoking - ways to reduce risk factors for cataracts consist of having regular eye examinations, wearing UVB block sunglasses, and protecting eyes with appropriate protection

ch. 6 differentiate between normal and abnormal findings of a mental health status and substance abuse assessment

- normal findings of the mental health status include alert, oriented to person, place, time, and events, appropriate response to questions, appropriate interaction, maintenance of eye contact, open eyes, GCS score of 15, relaxed, shoulders and back erect, rhythmic and coordinated gait, cooperative, appropriate affect, little to no anxiety, appropriate dress, clean and groomed, smiles and frowns, moderate tone and pace, clear speech, identification of objects, use of correct spelling and grammar, friendly, expresses feelings, PHQ-2 score of less than 2, QIDS score of 0-5, full and free-flowing thoughts, follows directions, verbalizes positive thoughts, does not have suicidal tendencies, no risk factors on SAD PERSONS, listens and follows directions, recalls recent events, remembers words after five, ten, and thirty minutes, explains similarities and differences between objects, uses sound rationale, draws the face of a clock, and SLUMS score of 27-30 with a high school education and 20-30 with less than high school - abnormal findings of the mental health status consist of not alert, not oriented to person, place, day, or time, inappropriate response to questions, inappropriate interaction, no eye contact, closed eyes, GCS score of less than 15, tense, shoulders and back rounded, stiff and uncomfortable gait, uncooperative, inappropriate affect, lots of anxiety, inappropriate dress, dirty and messy, no facial expressions, fast or slow tone and pace, unclear speech, no identification of objects, no use of correct spelling and grammar, unfriendly, does not express feelings, PHQ-2 score of more than 2, QIDS score of more than 5, hard to comprehend thoughts, does not follow directions, verbalizes negative thoughts, has suicidal tendencies, risk factors on SAD, does not listen and follow directions, does not recall recent events, does not remember words after five, ten, and thirty minutes, cannot explain similarities and differences between objects, does not use sound rationale, cannot draw the face of a clock, and SLUMS score of less than 27 with a high school education and 20 with less than high school

ch. 18 differentiate between normal and abnormal findings of the mouth, throat, nose, and sinuses

- normal findings of the mouth, throat, nose, and sinuses include smooth and moist lips, thirty two pearly white teeth with smooth surfaces, no decayed areas, no missing teeth, aligned jaws with no deviation, even color and consistency of cheek and gum tissues, pink, moist, and firm gums with tight margins to the tooth, smooth and moist tissue without lesions, Stensen ducts are visible with flow of saliva, pink and moist tongue with papillae, tongue without lesions, ventral surface is smooth, shiny, and pink with visible veins, frenulum is midline, Wharton ducts are visible, consistent salivary flow or moistness, strong resistance of tongue, distinguish between sweet and salty, hard palate is pale with firm transverse rugae (wrinkle folds), soft palate is pink, movable, spongy, and smooth, palatine tissues are intact, no unusual or foul odor, fleshy uvula hangs in the midline, no redness of uvula or soft palate, symmetric elevation of the soft palate, tonsils may be present or absent, tonsils are pink and symmetric, throat is normally pink without exudate or lesions, nose is the same color as the face, nasal structure is smooth and symmetric, sniff through each nostril, nasal mucosa is pink, moist, and free of exudate, nasal septum is intact and free of ulcers, superior turbinate is not visible, deviated septum may appear, frontal and maxillary sinuses are not tender to palpation, no crepitus, and sinuses are not tender on percussion - abnormal findings of the mouth, throat, nose, and sinuses consist of pallor around the lips, swelling of the lips, lesions on the lips, yellowish or brownish teeth, tooth decay, missing teeth, poor occlusion of teeth, receding gums, red and swollen gums that bleed easy, enlarged reddened gums (hyperplasia), chalky white raised patches (leukoplakia), Canker sores, Koplik spots, brown patches inside cheeks, reddened opening of Stensen ducts, dryness, nodules, ulcers, absent papillae or fissures, asymmetrical, raised whitish feathery areas, reddish and shiny tongue without papillae, persistant lesions or ulcers around or on tongue, decreased tongue strength, loss of taste discrimination, candidal infection, yellow tint to hard palate, opening in the hard palate (cleft palate), fruity, ammonia, foul, alcohol, tobacco, fecal, and sulfur odors, asymmetric or loss of movement, palate fails to rise, uvula deviates from midline, tonsils are red and enlarged, bright red throat with white or yellow exudate, nasal tenderness on palpation, not able to sniff through a nostril, nasal mucosa is swollen and pink, bluish gray, or red, purulent nasal discharge, ulcers of the nasal mucosa, perforated septum, small, pale, and round masses on mucosa (polyps), frontal or maxillary sinuses are tender to palpation, crepitus, large amount of exudate, sinuses are tender upon percussion

ch. 24 differentiate between normal and abnormal findings of the musculoskeletal system

- normal findings of the musculoskeletal system include erect and comfortable posture, evenly distributed weight, rhythmic and coordinated gait, no swelling, no tenderness, no pain, no spasms, mouth opens and closes smoothly, jaw protrudes and retracts easily, jaw has full ROM, no bony overgrowth, cervical and lumbar spines are concave, spine is straight, nontender spinous processes, well-developed and firm paravertebral muscles, flexion and extension of cervical spine of 45°, bend laterally 40°, rotate 70°, spine has full ROM, flexion of 75-90°, spinal processes are in alignment, lateral bending of 35°, hyperextension and rotation of 30°, equal leg measurements, symmetrical round shoulders, even clavicles and scapulae, shoulders and arms have full ROM, flexion and abduction of 180°, hyperextension and adduction of 50°, external and internal rotation of 90°, ability to shrug shoulders, symmetric elbows, without nodules, elbows have full ROM, flexion of 160°, extension of 180°, supination and pronation of 90°, symmetric wrists, tolerates hand squeeze test without pain, wrists have full ROM, flexion of 90°, hyperextension of 70°, ulnar deviation of 55°, radial deviation of 20°, no numbness or burning, no shocking or tingling, no flicking signal, can raise thumb, symmetric hands and fingers, hands and fingers have full ROM, abduction and adduction of 20°, flexion of 90°, hyperextension of 30°, thumb flexion of 50°, buttocks are equal, stable hips, hips have full ROM, hip flexion of 90-120°, abduction of 45-50°, adduction of 20-30°, internal hip rotation of 40°, external hip rotation of 45°, hyperextension of 15°, ability to stand, symmetric knees, legs in alignment no bulge of fluid, no movement of patella, knees have full ROM, flexion of 120-130°, hyperextension of 0-15°, no clicking, toes pointed forward and lie flat, no corns and calluses, longitudinal arches, ankles and feet have full ROM, dorsiflexion, eversion, and adduction of 20°, plantarflexion of 45°, inversion of 30°, abduction of 10°, flexion and extension of 40°, no plantar fasciitis, tolerates foot squeeze test with no pain, no psoriatic arthritis, and strength against resistance - abnormal findings of the musculoskeletal system consist of slumped shoulders, poor posture, abnormal curvatures of the spine, uneven weight bearing, limping gait, swelling, tenderness, pain, spasms, decreased ROM of the TMJ, crepitus, decreased muscle strength, clicking, popping, or grating, lack of full contraction, enlarged sternoclavicular joint, flattened lumbar curvature, lateral thoracic curvature, scoliosis, lordosis, kyphosis, tender spinous processes, undeveloped and soft paravertebral muscles, decreased ROM of the spine, unilateral exaggerated thoracic convexity, spinal processes out of alignment, low back strain, unequal leg measurements, flat and hollow shoulders, muscle atrophy, shoulder strains or sprains, arthritis, bursitis, degenerative joint disease, decreased ROM of shoulders and arms, inability to shrug shoulders, asymmetric elbows, firm and subcutaneous nodules, decreased ROM of elbows, asymmetric wrists, round and fluid-filled cysts, tolerates hand squeeze test with extreme pain, ulnar deviation, decreased ROM of wrists, numbness or burning, shocking or tingling, flicking signal, cannot raise thumb, asymmetric hands and fingers, decreased ROM of hands and fingers, shortened fingers, depressed knuckles, inability to extend fingers, buttocks are unequal, unstable hips, decreased ROM of hips, inability to stand, strains or tears of muscles or tendons, inability to abduct hips, knock knees, bowed legs, boggy consistency, asymmetric muscular development, bulge of fluid, movement of patella, decreased ROM of knees, clicking, toes pointed sideways and raised, corns and calluses, no arch, high arches, decreased ROM of ankles and feet, plantar fasciitis, tolerates foot squeeze test with extreme pain, psoriatic arthritis, hammer toe, and decreased strength against resistance

ch. 25 differentiate between normal and abnormal findings of the neurologic system

- normal findings of the neurologic system include correct identification of scent, 20/20 vision in both eyes, read print at 14 inches, full visual fields, pink retina, round optic disc, eyelid covers 2 mm of iris, eyes move in a smooth and coordinated motion, bilateral illuminated pupils constrict, temporal and masseter muscles contract, correct identification of sharp and dull, blinking bilaterally, ability to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and tightly close eyes, correct identification of flavor, ability to hear whispered words, uvula and soft palate rise bilaterally, gag reflex is intact, no difficulty swallowing, symmetric contraction of trapezius, strong contraction of sternocleidomastoid, smooth and symmetric tongue, fully developed muscles, voluntary contraction, no flaccidity, spasticity, or rigidity, no tics or tremors, gait is steady, opposite arms swing, maintains balance, stands erect, minimal swaying, bends knees while standing, hops on each foot, touches finger to nose, touches finger to thumb rapidly, runs each heel down shins, correct identification of light touch, correct identification of dull or sharp and hot or cold, correct identification of sensation, direction, and object, correct identification of area touched and number written, discrimination of one or two points, reflex score of 1+ to 3+, flexion and supination of forearm, extension and contraction of elbows and triceps, extension and contraction of knees and quadriceps, plantarflexion, no rapid contractions or oscillations, flexion of toes, contraction of abdominal muscles, elevation of scrotum, no pain or resistance of neck, no pain and flexion of hips and knees, and no pain and increased resistance to extension of knees - abnormal findings of the neurologic system consist of incorrect identification of scent, worse than 20/20 vision in either or both eyes, cannot read print at 14 inches, loss of visual fields, papilledema, optic atrophy, ptosis, eyes do not move in a smooth and coordinated motion, unilateral or neither illuminated pupils constrict, temporal and masseter muscles do not contract, incorrect identification of sharp and dull, blinking unilaterally or neither, inability to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and tightly close eyes, incorrect identification of flavor, inability to hear whispered words, uvula and soft palate do not rise bilaterally, gag reflex is not intact, difficulty swallowing, asymmetric contraction of trapezius, weak contraction of sternocleidomastoid, rough and asymmetric tongue, not fully developed muscles, involuntary contraction, flaccidity, spasticity, or rigidity, tics or tremors, gait is unsteady, same arms swing, does not maintain balance, does not stand erect, much swaying, cannot bend knees while standing, cannot hop on each foot, cannot touch finger to nose, cannot touch finger to thumb rapidly, cannot run each heel down shins, incorrect identification of light touch, incorrect identification of dull or sharp and hot or cold, incorrect identification of sensation, direction, and object, incorrect identification of area touched and number written, no discrimination of one or two points, reflex score of 0 or 4+, no flexion and supination of forearm, no extension and contraction of elbows and triceps, no extension and contraction of knees and quadriceps, no plantarflexion, rapid contractions or oscillations, no flexion of toes, no contraction of abdominal muscles, no elevation of scrotum, pain or resistance of neck, pain and flexion of hips and knees, and pain and increased resistance to extension of knees

ch. 30 differentiate between normal and abnormal assessment findings seen in the initial and subsequent assessments of the newborn

- normal findings of the newborn assessment include Apgar score of 8-10, pulse greater than 100 bpm, crying newborn, flexed extremities, active movement, pink body, acrocyanosis, 97.5-99°F (36.4-37.2°C), easy and non-labored breathing, clear bilateral lung sounds, respiratory rate of 30-53 breaths per min, regular pulse, range of 120-140 bpm, weight between 2,500 and 4,000 g, length between 44-55 cm, head circumference between 33-35.5 cm, chest circumference between 33-33 cm, flexed arms and legs, parchment skin, few or no vessels on abdomen, crackling, thinning and balding on back, shoulders, and knees, creases on sole of foot, raised and full areola, well-curved pinna, well-formed cartilage, instant recoil, appears stated age, no unusual body odor, clothing is in good condition, alert, active, responds appropriately to situation, interactive, seeks comfort from parent, appears happy, meets normal parameters for age, appropriate gross and fine motor skills, developed hand preference, temperature of 99.4°F, between 5th and 95th percentile for height and weight, soft, warm, and slightly moist skin, vernix caseosa, quick recoil for skin turgor, edema around eyes and genitalia, normocephalic and symmetric head, full ROM, head control, proportionate and symmetric face, equal and bilateral movements, normal sized parotid glands, short neck with skin folds, symmetrical and intact clavicles, eyelids have transient edema, clear sclera and conjunctiva, blue or brown iris, equal, round, reactive to light, and accomodating pupils, symmetric eyebrows, evenly distributed eyelashes, visual acuity of 20/100-20/400 by birth, visual acuity of 20/200 by 1 year, fixate on objects, follow moving objects, reach for objects, light reflects symmetrically in the center, vasoconstrict bilaterally, blink reflex occurs, present red reflex, pale optic discs, no unusual structures on pinna, no excessive cerumen or discharge, no lesions, no excoriations, no foreign bodies in the canal, amniotic fluid or vernix, pearly gray tympanic membrane, mobile tympanic membrane, Epstein's pearls on hard palate and gums, sucking tubercle on roof of mouth, pink and moist gums, teeth at 4-6 months, not visible tonsils, no discharge or tenderness, smooth, rounded, and symmetric thorax, unlabored and regular respirations, periodic irregular breathing, hyperresonance, louder and harsher breath sounds, no adventitious breath sounds, enlarged and engorged breasts, apical pulse at 4th intercostal space, innocent murmurs, prominent abdomen, pink umbilicus with no redness or herniation, normal bowel sounds, soft abdomen, no masses or tenderness, palpable liver, difficult to palpate spleen, difficult to palpate kidneys, slightly palpable bladder, normal sized penis, no lesions, diaper rashes, retractable foreskin, no discharge or redness, lower left testicle, equal and smooth testes, no inguinal hernias, pink and moist labia majora and minora, prominent newborn's genitalia, bruises and swelling, psuedomenstruation, smegma of sebaceous gland, reddish or orange urine, stains on diaper, visible and moist anal opening, perianal skin tags, symmetric and warm extremities, adequate capillary refill, tibial torsion, equal gluteal folds, full hip abduction, negative Ortolani sign, negative Barlow sign, flexible and rounded spine, full ROM, no swelling, redness, or tenderness, adequate muscle size and strength, lusty and strong cries, responds appropriately to stimuli, infantile reflexes are present, and Babinski response is normal - abnormal findings of the newborn assessment consist of Apgar score of less than 8, pulse less than 100 bpm, absent, slow, or irregular crying, delayed neurologic function, no response, grimace, cyanotic or pale skin, less than 97.5°F (36.4°C), hypothermia, greater than 99°F (37.2°C), hyperthermia, labored breathing, nasal flaring, rhonchi, rales, retractions, grunting, irregular pulse, range below 30 bpm or above 60 bpm for respiratory distress, range greater than 180 bpm or less than 100 bpm for cardiac abnormalities, weight less than 2,500 g or greater than 4,000 g, length less than 44 cm or greater than 55 cm, head circumference less than 33 cm or greater than 35.5 cm, chest circumference less than 29 cm or greater than 34 cm, limp arms and legs, translucent skin, visible veins, rashes, lathery and wrinkled skin, abundant amounts of fine hair, absence of breast tissue, slightly curved pinna, slow recoil, facies that indicate acute illness and respiratory distress, flaccidity or rigidity in newborn, poor hygiene and clothes, does not appear stated age, lags in earlier stages, inappropriate gross and fine motor skills, undeveloped hand preference, altered temperature, below 5th percentile or above 95th percentile for height and weight, abnormal skin lesions, pallor, ruddy complexion, jaundice, dirty and matted hait, tufts of hair over spine, blue nailbeds, yellow nailbeds, blue-black nailbeds, hydrocephaly, oddly shaped head, third fontanelle, premature closure of sutures, craniotabes, bulging fontanelle, microencephaly, hyperextension, limited ROM, unusual proportions, abnormal facies, wide-set position, upward slant, thick epicanthal folds, eyelid inflammation, purulent discharge, lacrimal duct obstruction, yellow sclera, blue sclera, brushfield spots, sluggish pupils, sparseness of eyebrows or eyelashes, one-line difference between eyes, unequal alignment of light on pupils, doll's eye reflex, absence of red reflex, congenital defects, low-set ears, abnormal shape of pinna, foreign body obstruction, purulent or serous discharge, presence of foreign bodies in canal, immobility, absence of reacyins, white discahrge, cleft lip and/or palate, lesions and edema, extension of frenulum to the tip of tongue, choanal atresia, deviated septum, foul discharge, abnormal shapes of thorax, retractions and grunting, periods of apnea longer than 15 seconds, nasal flaring, tachypnea, seesaw movement, dull tone, diminished breath sounds, stridor, expiratory wheezes, rhonchi and rales, palpable mass of the breast, extra nipples, systolic heave, murmurs, extra heart sounds, scaphoid abdomen, distended abdomen, inflammation, discharge, and redness of umbilicus, diastasis recti, bulge at umbilicus, abnormal insertion of cord, marked peristaltic waves, rigid abdomen, no bowel movement within 48 hours, enlarged liver with firm edge, enlarged spleen, enlarged kidneys, enlarged bladder, unretractable foreskin, paraphimosis, hypospadias, epispadias, absent testicles, atrophic scrotum, cryptorchidism, hydroceles, scrotal hernia, bulge in the inguinal area, enlarged clitoris, imperforate anus, pustules, no passage of stool, short and broad extremities, hyperextensible joint, palmar simian crease, polydactyly, syndactyly, neurovascular deficit, fixed-position deformities, metatarsus varus, talipes varus, talipes equinovarus, unequal gluteal folds, limited hip abduction, positive Ortolani sign (click along femur and hip), positive Barlow sign (femur slipping out of hip), flaccid or rigid posture, limited ROM, swelling, redness, tenderness, inadequate muscle size and strength, inappropriate response to stimuli, infantile reflexes are absent or asymmetric, and no Babinski response

ch. 22 differentiate between normal and abnormal findings of the peripheral vascular system

- normal findings of the peripheral vascular system include bilaterally symmetric limbs, consistent skin color, warm skin, capillary beds refill in two seconds or less, pulses are bilaterally strong, epitrochlear lymph nodes are not palpable, no changes in pigmentation, hair covers skin of the legs and tops of the toes, no lesions or ulcers, no swelling or atrophy, no edema, bilateral temperature, nontender and movable lymph nodes, no auscultated sounds, and flat veins - abnormal findings of the peripheral vascular system consist of lymphedema, vasoconstriction, vasospasm, cold extremity, capillary beds take longer than two seconds to refill, increased pulse volume, diminished or absent pulses, enlarged and immobile lymph nodes, pallor, rubor, arterial insufficiency, cyanosis, loss of hair, thin and shiny skin, ulcers with smooth and even margins, ulcers with irregular edges and bleeding, bilateral edema, pitting edema, generalized coolness, and distended and bulging varicose veins

ch. 27 discuss risk factors associated with cervical cancer across the cultures and ways to reduce one's risks

- risk factors for cervical cancer include human papilloma virus infection, smoking, immunosuppression, chlamydia infection, diet low in fruits and vegetables, obesity, intrauterine device use, multiple full-time pregnancies, being younger than 17 at first pregnancy, poverty, having a mother who took diethylstilbestrol, and family history of cervical cancer - ways to reduce risk factors for cervical cancer consist of avoid risky sexual practices, consult with healthcare professions about HPV vaccines, come in for routine pap smears, maintain a careful preventive screening schedule, eat nutritious food, have routine care for illnesses, and talk to partner about sexual health expectations

ch. 17 differentiate between general routine screening versus skills needed for focused or specialty assessment of the ear and hearing

- the general routine screening of the ears and hearing includes the whisper test and assessment of the inner and external ear - the specialty assessment of the ears and hearing consists of the Weber, Rinne, and Romberg tests when ears or hearing has been assessed and problems have been determined

ch. 14 differentiate between normal and abnormal findings of the skin, hair, and nails

- normal findings of the skin, hair, and nails include evenly colored skin, no odor of perspiration, suntanned areal freckles or white patches (vitiligo), intact skin, no reddened areas, without lesions, smooth and even skin, normally thin but calluses might be present, vary moist to dry depending on area assessed, a warm temperature, mobile and elastic, rebounds and does not remain indented, clean and dry scalp, smooth and firm hair, fine vellus hair covering the entire body except for soles, palms, lips, and nipples, normal male pattern balding is symmetric, clean and manicured nails, pink tones, 160° angle between nail base and skin, hard and immobile nails, smooth and firms nails, and pink tones return to nail bed immediately when pressure is released - abnormal findings of the skin, hair, and nails consist of pallor (loss of color), cyanosis (blue skin), jaundice (yellow skin), acanthosis nigricans (velvet darkening), strong odor of perspiration, rashes and color variations, skin breakdown, lesions indicating local or systemic problems, rough, flaky, dry, and itchy skin, very thin skin, tender lesions, increased moisture or diaphoresis, clammy skin, abnormally cool or warm skin, decreased mobility, decreased turgor, indentations on the skin, patchy gray hair, excessive scaliness, dull and dry hair, pustules with hair loss, infections of the hair follicle, excessive generalized hair loss, patchy hair loss, hirsutism (facial hair on females), dirty, broken, or jagged fingernails, pale or cyanotic nails, early clubbing (180° with spongy sensation) or late clubbing (greater than 180°), thickened nails, paronychia, detachment of nail plate from nail bed, and slow capillary nail bed refill greater than two seconds

ch. 13 differentiate between normal and abnormal nutrition, hydration, and food safety practices

- optimal nutrition requires a balance of nutrient intake to meet daily metabolic demands and vary based on developmental level, lifestyle, and other energy demands - malnutrition is caused by lower socioeconomic status, long work hours, poor food choices, chronic dieting, chronic diseases, dental factors, limited access to sufficient food, disorders where food is self-limited, illness or trauma - overnutrition is caused by increased caloric consumption, foods high in fat and sugar, decreased energy expenditure, excessive body fat in relation to lean body mass, someone who is 10% over IBW is overweight, and someone who is 20% over IBW is obese - optimal hydration is usually four liters of water for men and two liters of water for women a day and is crucial to a patient's health and wellbeing - dehydration can have a seriously damaging effect on body cells and the execution of body functions - overhydration is serious to those with kidney, liver, and cardiac diseases as it can impair the fluid dynamic mechanisms - food safety practices include how a patient's food is stored and prepared in a safe and healthy manner and also involves food intolerances (digestive system irritation) and food allergies (immune system response)

ch. 9 discuss the various physiological responses to pain

- pain elicits a stress response in the body that triggers the sympathetic nervous system - anxiety, fear, hopelessness, sleeplessness, and thoughts of suicide - focus on pain, reports of pain, cries and moans, frowns, and grimaces - decrease in cognitive functions, mental confusion, altered temperament, high somatization, and dilated pupils - increased heart rate, increased blood pressure, and peripheral, somatic, and coronary vascular resistance - increased respiratory rate, increased sputum retention, and infection and atelectasis - decreased gastric and intestinal motility - decreased urinary output, urinary retention, fluid overload, and depression of all immune responses - increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, and glucagon - decreased insulin and testosterone - hyperglycemia, glucose intolerance, insulin resistance, and protein catabolism - muscle spasm, impaired muscle function, immobility, and perspiration

ch. 9 assess pain as the fifth vital sign

- pain is whatever the patient says it is - nociceptive pain is a response to noxious insult or injury of tissues - neuropathic pain is initiated or caused by a primary lesion or disease in the somatosensory nervous system - inflammatory pain is a result of activation and sensitization of the nociceptive pain pathway by a variety of mediators released at a site of tissue inflammation - cutaneous pain involves the skin or subcutaneous tissue - visceral pain involves the abdominal cavity, thorax, and cranium - deep somatic pain involves the ligaments, bones, blood vessels, and nerves - pain can be radiating where it is perceived both at the source and extending to other tissues - pain can also be referred where it is perceived in body areas away from the pain source - phantom pain can be perceived in nerves left by a missing, amputated, or paralyzing body part - physical dimension refers to the physiologic effects - sensory dimension concerns the quality of the pain and how severe the pain is perceived to be - behavioral dimension refers to the verbal and nonverbal behaviors that the patient demonstrates in response to the pain - sociocultural dimension concerns the influences of the patient's social context and cultural background on the patient's pain experience - cognitive dimension concerns beliefs, attitudes, intentions, and motivations related to pain and its management

ch. 2 discuss the purpose for each of the four phases of a client interview

- preintroductory phase: nurse reviews the medical record before meeting with the client - introductory phase: nurse introduces herself to the client, explains the purpose of the interview, discusses the types of question, explains the reason for taking notes, and assures the client that it is strictly confidential information - working phase: nurse elicits the client's comments about major biographical data, reasons for seeking care, history of health concern, past history, family history, review of systems (ROS), health practices, and developmental level - summary/closing phase: nurse summarizes information obtained during the working phase and validates problems and goals with the client

ch. 20 discuss risk factors associated with breast cancer across the cultures and ways to reduce one's risks

- risk factors for breast cancer include female gender, Caucasians, old age, genetics, personal history, family history, breast consistency, early menstruation, previous chest radiation, diethylstilbestrol, no children, oral contraceptive use, hormone replacement therapy, no breast-feeding, alcohol consumption, obesity, weight gain, limited physical activity, dim light at night, night work, exposure to secondhand smoke, diet, and vitamin intake are all risk factors of breast cancer - ways to reduce risk factors for breast cancer consist of get intentional physical exercise, avoid alcohol intake, avoid excessive weight gain, be aware of increased risk if client has no children, note breast consistency, consider family history, avoid night shift work, avoid second hand smoke, avoid dim light while sleeping, and advise client to talk with healthcare provider

ch. 17 discuss the risk factors for hearing loss across cultures and ways to reduce one's risks

- risk factors for hearing loss include aging, heredity, occupational loud noises, recreational noises, exposure to explosive noises, ototoxic medications, illnesses, group childcare, babies fed from a bottle (lying down), seasons of fall and winter, poor air quality, family history, cleft palate, down syndrome, ethnicity, and enlarged adenoids - ways to reduce risk factors for hearing loss are avoiding sound exposure louder than a washing machine, avoiding recreational risks, not listening to extremely loud music, wearing ear protectors, getting hearing checked periodically, obtaining devices to improve hearing, immunizing children against childhood diseases, and immunizing for rubella before pregnancy

ch. 19 discuss the risk factors for lung cancer across the cultures and ways to reduce one's risks

- risk factors for lung cancer include male gender, African Americans, environment, personal history, family history, and diet are all risk factors of lung cancer - ways to reduce risk factors for cataracts consist of avoid smoking cigarettes or join a tobacco cessation program, avoid secondhand smoke exposure, have home or office checked for asbestos or radon, use protective gear when around environmental substances that may be irritating to the lungs, avoid taking beta-carotene supplements, and seek a medical assessment for respiratory symptoms

ch. 18 discuss risk factors across cultures for oral cancer and ways to reduce one's risks

- risk factors for oral cancer include tobacco products, heavy alcohol use, drinking alcohol and smoking together, HPV infection, exposure to sunlight, male gender, age over 55, fair skin, poor oral hygiene, poor diet and nutrition, chewing betel quid or gutka (Southeast Asia tobacco mixtures), weakened immune system, graft-versus-host disease, genetic syndrome, lichen planus (itchy rash skin disorder), use of mouthwash with high alcohol content, and irritation from dentures - ways to reduce risk factors for oral cancer consist of avoiding smoking cigarettes, using oral tobacco, excessive alcohol use, chewing betel nuts, infection with HPV, and excessive sun exposure, eating a diet rich in fruits, vegetables, vitamin A, and well rounded, practicing regular oral hygiene, taking extra precautions with weakened immune system, avoiding use of mouthwash with high alcohol content, and having dentures checked for good fit

ch. 22 discuss risk factors associated with peripheral vascular disease across the cultures and ways to reduce one's risk

- risk factors for peripheral vascular disease include old age (50+ years), African Americans, diabetes, atherosclerosis, smoking, obesity, high blood pressure, high cholesterol, family history of PVD, and high homocysteine are all risk factors of peripheral vascular disease - ways to reduce risk factors for peripheral vascular disease consist of quit smoking, keep blood sugar in control, exercise regularly, lower cholesterol, lower blood pressure, eat a well-rounded diet, maintain a healthy weight, and screen with an ABI measurement

ch. 26 discuss risk factors associated with prostate and testicular cancer across the cultures and ways to reduce one's risks

- risk factors for prostate and testicular cancer include increasing age, male gender, African American and Caribbean races, North America and Europe countries, family history, certain gene changes, exposure to agent orange, alcohol consumption, working on a farm or in a tire plant, diet high in red meat and high fat, low melatonin levels, obesity, prostatitis, sexually transmitted infections, vasectomy, and smoking tobacco - ways to reduce risk factors for prostate and testicular cancer consist of ejaculate frequently, eat a diet high in fruits and vegetables, stay physically active, maintain a healthy weight, take vitamin E and selenium, sleep in a dark room, avoid the night shift, and drink green tea daily

ch. 14 discuss risk factors for skin cancer and methicillin-resistant Staphylococcus aureus infections

- risk factors for skin cancer include sun exposure, intermittent pattern with sunburn, non-solar sources of UVR, medical therapies (PUVA or ionizing radiation), family or personal history and genetic susceptibility, moles, pigmentation irregularities, fair skin that burns and freckles easily, age, actinic keratoses, male gender, white race, chemical exposure, human papillomavirus, xeroderma pigmentosum, longterm skin inflammation or injury, alcohol intake, smoking, inadequate vitamin B3 in diet, Bowen disease, and depressed immune system - risk factors for Staphylococcus aureus consists of impaired skin integrity, invasive medical devices, residing in a longterm care facility, presence of a MRSA-positive patient, contact sports, sharing personal items, suppression of immune system function, unsanitary or crowded living conditions, working in the healthcare industry, receiving antibiotics within the past three to six months, young or old age, men having sex with men, and hemodialysis

ch. 25 discuss risk factors associated with a cerebral vascular accident (CVA), commonly known as stroke, across the cultures and ways to reduce one's risks

- risk factors for stroke include hypertension, diabetes mellitus, heart disease, smoking, increasing age, male gender, oral contraceptives, African American, Native American, and Alaska native races, personal or family history of stroke, brain aneurysms, arteriovenous malformations, alcohol intake, illegal drug use, sickle cell disease, vasculitis, bleeding disorders, lack of physical activity, overweight and obesity, stress, depression, unhealthy cholesterol levels, unhealthy diet, and use of NSAIDs - ways to reduce risk factors for stroke consist of not smoking, controlling cholesterol, high blood pressure, and diabetes, exercising for 30 minutes a day, maintaining a healthy weight, choosing a diet rich in fruits, vegetables, and whole grains, choosing lean proteins, choosing low-fat dairy products, avoiding sodium and fats, eating fewer animal products, reading labels, limiting alcohol intake, avoiding illegal drug use, avoiding oral contraceptives, and taking aspirin or clopidogral to prevent blood clots

ch. 23 discuss risk factors associated with diseases of abdominal organs across the cultures and ways to reduce one's risks

- risk factors of abdominal diseases includes use of NSAIDS or bisphosphates, smoking or chewing tobacco, H. pylori in the GI tract, stress, hypersecretory condition, personal history of ulcers, family history of ulcers, radiation treatments, Zollinger-Ellison syndrome, obesity, hiatal hernia, pregnancy, smoking, dry mouth, asthma, diabetes, delayed stomach emptying, connective tissue disorders, and alcohol consumption are all risk factors of abdominal diseases - ways to reduce risk factors for abdominal diseases consist of wash hands frequently, eat thoroughly cooked foods, use recommended cautions, avoid excessive alcohol, stop smoking, and take prescribed medications

ch. 21 discuss the risk factors for coronary heart disease (CHD or CAD) across cultures and ways to reduce one's risks

- risk factors of coronary heart disease include increasing age (65+), male gender, heredity, African Americans, Mexican Americans, Native Americans, native Hawaiians, Asians, smoking tobacco, secondhand smoke, high blood cholesterol, high triglycerides, hypertension, physical inactivity, obesity and overweight, diabetes mellitus, stress, excessive alcohol consumption, and diet and nutrition are all risk factors of coronary heart disease - ways to reduce risk factors for coronary heart disease consist of stop smoking, choose a healthy diet, reduce elevated cholesterol, lower blood pressure, increase physical activity, maintain a healthy weight, manage diabetes, limit alcohol intake, and practice stress reducing techniques

ch. 13 differentiate between skills needed for routine nutritional screening versus skills needed for a comprehensive nutritional assessment

- routine nutritional screening assessess overall appearance, muscle mass, fat distribution, changes, intake and output, skin turgor, IBW, BMI, condition of skin, veins, tongue, eyes, and lung sounds - comprehensive nutritional assessment evaluates waist circumference, waist-to-hip ratio, MAC, TSD, and MAMC

ch. 3 describe various client positions used for different parts of the physical examination

- sitting position: the patient sits upright on the side of the examination table and the nurse evaluates the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities - supine position: the client lies down with their legs together and the nurse assesses the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities - dorsal recumbent position: the patient lies down with their knees bent, legs separated, and feet flat and the nurse evaluates the head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses - sims' position: the client lies on their right or left side with the lower arm behind the body and upper arm flexed and pulled forward and the nurse assesses the rectal and vaginal areas - standing position: the patient stands still in a comfortable and resting posture and the nurse evaluates posture, balance, gait, and male genitalia - prone position: the client lies down on the abdomen with the head to the side and the nurse assesses the hip and back - knee-chest position: the patient kneels with a 90-degree angle between the body and hips and the arms placed above the head with the head turned to one side and the nurse assesses the rectum - lithotomy position: the client lies on the back with the hips at the edge and the feet supported by stirrups and the nurse evaluates the female genitalia, reproductive tracts, and rectum

ch. 4 use SBAR (situation, background, assessment, and recommendation) method to verbally report client data to another health care provider

- situation: state concisely why you need to communicate the client data you have assessed - background: describe the events that led up to the current situation - assessment: state the subjective and objective data you have collected - recommendation: suggest what you believe needs to be done for the client based on your assessment findings

ch. 33 determine a family's life cycle stage and related tasks

- stage I: beginning families (stage of marriage) establishes a mutually satisfying marriage, relates harmoniously to the kin network, and plans a family (decisions about parenthood) - stage II: childbearing families (oldest child is infant through 30 months) sets up the young family as a stable unit (integrating new baby into family), reconciles conflicting developmental tasks and needs of various family members, maintains a satisfying marital relationship, and expands relationships with extended family by adding parenting and grandparenting roles - stage III: families with preschool children (2.5-6 years) meets family members' needs for adequate housing, space, privacy, and safety, socializes the children, integrates new child members while still meeting the needs of other children, and maintains healthy relationships within the family (marital and parent-child) and outside the family (extended family and community) - stage IV: families with schoolchildren (6-13 years) socializes the children including promoting school achievement and fostering of healthy peer relations of children, maintains a satisfying marital relationship, and meets the physical health needs of family members - stage V: families with teenagers (13-20 years) balances freedom with responsibility as teenagers mature and become increasingly autonomous, refocuses the marital relationship, and communicates openly between parents and children - stage VI: launching young adults (from first to last child leaving home) expands the family circle to include new family members acquired by marriage of children, continues to renew and readjust in the marital relationship, and assists aging and ill parents of the husband or wife - stage VII: middle-aged parents (empty nest through retirement) provides a health-promoting environment, sustains satisfying and meaningful relationships with aging parents and adult children, and strengthens the marital relationship - stage VIII: family in retirement and old age (retirement to death of both spouses) maintains a satisfying living arrangement, adjusts to a reduced income, maintains marital relationships, adjusts to loss of spouse, maintains intergenerational family ties, and continues to make sense out of one's existence (life review and integration)

ch. 8 prepare the client for a survey of general health status and vital signs

- survey their physical development, body build, gender, sexual development, apparent age to reported age, skin condition and color, dress, hygiene, posture, gait, level of consciousness, behaviors, body movements, affect, facial expressions, and speech - measure their temperature, pulse, respiration, blood pressure, and pain

ch. 16 assess a client's distant and near visual acuity, visual fields, corneal light reflex, and eye movements

- test distant visual acuity with the Snellen or E chart, the client stands 20 feet away from the chart at eye level and covers one eye, and they read each line of letters until they can no longer distinguish them - evaluate near visual acuity with the Jaeger test, the client holds a pocket screener 14 inches away from the eyes, and they reach each line without moving the print closer or further away to see - assess visual fields with the confrontation test, the nurse stands in front of the client two feet away and has them cover one eye, they raise their hands from the sides, diagonals, and above and below until the client can see their hands - test corneal light reflex with the parallel alignment test, the nurse shines a penlight 12 inches back and forth from client's face, and notes the light reflected on the corneas - evaluate eye movements with the cardinal fields of gaze test, the client focuses on an object 12 inches away, and the nurse moves an object in a clockwise direction to observe the client's eye movements

ch. 20 describe the structure and the function of the breast and major axillary lymph nodes

- the (female) breasts produce and store milk that provides nourishment for newborns and aid in sexual stimulation, are paired mammary glands that lie over the muscles of the anterior chest wall - the major axillary lymph nodes drain lymph from the breasts to filter out microorganisms and return water and protein to the blood, are divided into the lateral (brachial), central (midaxillary), posterior (subscapular), and anterior (pectoral) lymph nodes

ch. 13 describe various factors that affect food safety and place the client at risk for food poisoning

- the CDC noted that there are more than 250 different food-borne illnesses - causes are infections (bacteria, viruses, and parasites) and poisonings from contaminations with toxins or chemicals - symptoms are usually nausea, vomiting, abdominal cramps, and diarrhea - the nurse is in a unique position to assess the client's knowledge of food safety and preparation and educate clients regarding appropriate food safety measures

ch. 23 discuss the organs located in the four quadrants and nine regions of the abdomen

- the RUQ has the ascending and transverse colon, duodenum, gallbladder, hepatic flexure of colon, liver, head of pancreas, pylorus of ileum, right adrenal gland, upper pole of right kidney, and right ureter - the LUQ has the left adrenal gland, upper pole of left kidney, left ureter, body and tail of pancreas, spleen, splenic flexure of colon, stomach, and transverse descending colon - the RLQ has the appendix, ascending colon, cecum, lower pole of right kidney, right ovary and tube, right ureter, and right spermatic cord - the LLQ has the lower pole of left kidney, left ovary and tube, left ureter, left spermatic cord, descending colon, and sigmoid colon - the midline has the bladder, uterus, and prostate gland

ch. 22 describe the structure and function of the blood vessels, including capillaries and lymphatic circulation

- the arteries carry oxygenated, nutrient-rich blood from the heart to the capillaries, arterial walls are thick, strong, and elastic - the veins carry deoxygenated, nutrient-poor, waste-laden blood from the tissues back to the heart, vein walls are much thinner and larger in diameter if blood volume increases - the capillaries form the connection between the arterioles and venules, they allow the circulatory system to maintain the vital equilibrium between the vascular and interstitial spaces - the lymphatic circulation is a complex vascular system composed of lymphatic capillaries, vessels, and nodes, they drain excess fluid and plasma proteins from bodily tissues and return them to the venous system

ch. 3 discuss the purpose of the bell and diaphragm of the stethoscope

- the bell of the stethoscope listens for low pitched sounds, such as abnormal heart sounds and bruits (abnormal loud, blowing, or murmuring sounds) - the diaphragm of the stethoscope listens for high pitched sounds, such as normal heart sounds, breath sounds, and bowel sounds

ch. 26 explain the correct method for teaching a client how to perform a testicular self-examination

- the eight steps of a testicular self-examination - stand in front of a mirror and check for scrotal swelling - use both hands to palpate the testis - with the index and middle fingers under the testis and thumb on top, roll the testis gently in a horizontal plane between the fingers - feel for any evidence of a small lump or abnormality - follow the same procedure and palpate upward along the testis - locate the epididymis on the top and back of the testicle - repeat the examination for the other testis - consult a physician if any evidence of a small and pea-like lump is found

ch. 16 describe the structures and functions of the eyes

- the eyes transmit visual stimuli to the brain for interpretation and function as the organ of vision - a visual field refers to what a person sees with one eye - external structures of the eye include the eyelids (protect eyes from foreign bodies and distribute tears), lateral and medial canthus, palpebral fissure, eyelashes (filter dust and dirt), conjunctiva (inspects underlying tissue and protects the eyes), lacrimal apparatus, and extraocular muscles (control six different directions of eye movement) - internal structures of the eye consist of the sclera (supports the internal structures), cornea (permits the entrance of light and responds to pain and touch), iris (determines eye color), ciliary body (focuses on objects near and far), choroid, pupil (controls light entering the eye), lens, retina (receives visual stimuli and sends it to the brain), rods (function in dim light), cones (sensitive to color), optic disc (connects optic nerve to eyeball), retinal vessels, fovea centralis, macula, and chambers

ch. 27 describe the structure and function of the female genitalia, anus, and rectum

- the female external genitalia consists of the vulva, mons pubis, symphysis pubis, labia majora, labia minora, prepuce, frenulum, clitoris, glans, corpus, crura, vestibule, urethral meatus, Skene glands, lesser vestibular glands, vaginal orifice, hymen, Bartholin glands, and greater vestibular glands, the mons pubis absorbs force and protects the symphysis pubis, the labia majora contain adipose tissue, sebaceous glands, and sweat glands, the clitoris has many blood vessels to aid in sexual arousal, the Skene glands lubricate and maintain a moist vaginal environment, the Bartholin glands lubricate the area during sexual intercourse - the female internal genitalia consists of the vagina, cervix, uterus, fallopian tubes, and ovaries, the vagina allows the passage of menstrual flow, receives the penis during sexual intercourse, and serves as the lower portion of the birth canal, the cervix allows the entrance of sperm into the uterus and passage of menstrual flow, the ovaries develop and release ova and produce the hormones estrogen, progesterone, and testosterone - the anus functions in detection and elimination from the digestive system and consists of internal and external sphincters, somatic sensory nerves, anal verge, anorectal junction, columns of Morgagni, arteries, veins, and visceral nerves - the rectum functions in unknown ways and consists of anorectal junction, sigmoid colon, rectal ampulla, valves of Houston, and peritoneum - the prostate functions in promotes sperm motility and neutralization of female acidic vaginal secretions and consists of two lobes, seminal vesicles, and bulbourethral glands

ch. 20 explain the correct method for teaching a client how to perform self breast examination

- the five steps of a breast self-examination - look at breasts in the mirror with shoulders straight and arms on hips, check size, shape, and color, notice if they are evenly shaped with no distortion or swelling - raise arms and determine if changes are the same on both sides - look for any signs of fluid coming out of one or both nipples - lie down with right arm behind head, use the three middle finger pads and move them in a circular motion from top to bottom (collarbone to abdomen) and side to side (armpit to cleavage), use light pressure for superficial skin and tissue, use medium pressure for tissue in the middle of breasts, and use firm pressure for the deep tissue in the back, and repeat with the other side with left arm behind head - cover the entire breast using the same hand movements in the previous step, many women find it easiest to do this in the shower when the skin is wet and slippery

ch. 23 differentiate between general routine screening versus skills needed for focused or specialty assessment of the abdomen

- the general routine screening of the abdomen includes the observation of color, vascularity, scars, rashes, lesions, umbilicus, abdominal contour, symmetry, aortic pulsations, and peristaltic waves, auscultation of bowel sounds, percussion of tones over four quadrants of abdomen, and light palpation of four quadrants - the specialty assessment of the abdomen consists of the auscultation of vascular sounds, percussion of (size of) liver, spleen, and kidneys, deep palpation of four quadrants, palpation of aorta, liver, spleen, kidneys, urinary bladder, shifting, and dullness, perform fluid wave test, assessment for rebound tenderness, test for referred rebound tenderness, assessment for psoas sign and obturator sign, perform hypersensitivity test, and test for cholecystitis

ch. 33 differentiate between general routine screening versus skills needed for focused or specialty assessment of the family

- the general routine screening of the family assessment includes the determination of strengths and problem areas within the family's structure and function that influence the development of the illness and family's ability to support the client - the specialty assessment of the family assessment consists of the view of the family unit as a system and care to the individual and family as a dynamic system

ch. 27 differentiate between general routine screening versus skills needed for focused or specialty assessment of the female genitalia, anus, and rectum

- the general routine screening of the female genitalia, anus, rectum, and prostate includes the inspection of the mons pubis, labia majora, perineum, labia minora, clitoris, urethral meatus, vaginal opening, perianal area, and sacrococcygeal area - the specialty assessment of the female genitalia, anus, rectum, and prostate consists of the palpation of the Bartholin glands and urethra, inspection of the size of the vaginal opening and angle, vaginal musculature, cervix, vagina, and vaginal walls, palpation of the vaginal wall, cervix, uterus, ovaries, rectum, rectal sphincter, and perform the rectovaginal examination

ch. 21 differentiate between general routine screening versus skills needed for focused or specialty assessment of the heart and neck vessels

- the general routine screening of the heart and neck vessels includes the inspection of jugular venous pulse, auscultation and palpation of carotid arteries, inspection of pulsations on anterior chest, palpation of apical impulse and abnormal pulsations, and auscultation of S1 and S2, extra heart sounds, and murmurs - the specialty assessment of the heart and neck vessels consists of the evaluation of jugular venous pressure, grade and identification of auscultated murmurs, and differentiation between split sounds, rubs, snaps, and clicks

ch. 26 differentiate between general routine screening versus skills needed for focused or specialty assessment of the male genitalia, anus, rectum, and prostate

- the general routine screening of the male genitalia, anus, rectum, and prostate includes the inspection of the penis, pubic hair, scrotum, inguinal and femoral areas, perianal area, anus and rectum, and stool - the specialty assessment of the male genitalia, anus, rectum, and prostate consists of the palpation of the penis, pubic hair, scrotum, urethral discharge, spermatic cord, vas deferens, epididymis, inguinal ring, transillumination of the scrotum, palpation of the inguinal and femoral hernia, inguinal lymph nodes, and anus and rectum

ch. 6 differentiate between skills needed for general routine screening and skills needed for focused specialty assessment of mental status and risk for substance abuse

- the general routine screening of the mental status includes the observation of LOC, posture, gait, body movements, behavior, affect, dress, grooming, and facial expressions, assessment of speech orientation, concentration, observation of mood, feelings, expressions, thought processes, perceptions, and assessment of recent and remote memory - the specialty assessment of the mental status consists of the testing of the Glasgow Coma Scale, PHQ-9, Quick Inventory of Depressive Symptomatology, Columbia Suicide Severity Rating Scale, SBIRT, CAGE, AUDIT, Geriatric Depression Scale, SAD PERSONS, SLUMS, assessment of abstract reasoning, cognitive impairment, and visual, perceptual, and constructional ability

ch. 18 differentiate between general routine screening versus skills needed for focused or specialty assessment of the mouth, throat, nose, and sinuses

- the general routine screening of the mouth, throat, nose, and sinuses includes the inspection of lips, odors from the mouth, teeth, gums, tongue, and buccal mucosa, external nose, patency of air flow through the nostrils, and throat - the specialty assessment of the mouth, throat, nose, and sinuses consists of the palpation of buccal mucosa and tongue, assessment of the ventral surface and sides of the tongue, inspection for Wharton and Stensen ducts, checking the tongue's strength and ability to taste, inspection of the hard and soft palates and uvula, assessment of the uvula, tonsils, and posterior pharyngeal wall, inspection of the internal nose, and palpation, percussion, and transillumination of the sinuses

ch. 24 differentiate between general routine screening versus skills needed for focused or specialty assessment of the musculoskeletal system

- the general routine screening of the musculoskeletal system includes the observation of posture and gait, inspection of the TMJ, sternoclavicular joint, cervical, thoracic, and lumbar spine, shoulders, arms, and elbows, wrists, hands, and fingers, and hips, knees, ankles, and feet, palpation of the TMJ, sternoclavicular joint, cervical, thoracic, and lumbar spine, shoulders, arms, and elbows, wrists, hands, and fingers, and hips, knees, ankles, and feet - the specialty assessment of the musculoskeletal system consists of the measurement of ROM of the TMJ, cervical and lumbar spine, shoulders, elbows, wrists, and fingers, hips, knees, ankles, and toes, palpation of the anatomic snuffbox, test for carpal tunnel syndrome and thumb weakness, observation for the flick signal, perform the squeeze test of the hands and feet, measurement of leg length, perform the bulge test and ballottement test

ch. 25 differentiate between general routine screening versus skills needed for focused or specialty assessment of the neurologic system

- the general routine screening of the neurologic system includes the assessment of level of consciousness, observation of behavior, affect, dress, grooming, hygiene, facial expressions, and speech, assessment of mood, feelings, expressions, CN II, evaluation of posture, gait, balance, involuntary movements, and assessment of light touch and pain - the specialty assessment of the neurologic system consists of the assessment of thought processes, perceptions, orientation, concentration, recent and remote memory, use of memory to learn, abstract reasoning, judgment, SLUMS test, visual ability, perceptual ability, constructional ability, testing of CN I through XII, performance of Romberg test, assessment of coordination, rapid alternating movements, light touch, pain, temperature sensations, and testing of vibratory sensation, sensitivity to position, tactile discrimination, point localization, graphesthesia, extinction, superficial and deep tendon reflexes, and meningeal irritation

ch. 30 differentiate between general routine screening versus skills needed for focused or specialty assessment of the newborn

- the general routine screening of the newborn includes testing distant visual acuity, near visual acuity, visual fields for gross peripheral vision, inspection of eyelids and eyelashes, observation of position and alignment of the eyeball, inspection of bulbar conjunctiva, sclera, lacrimal apparatus, iris, pupil, and testing pupillary reaction to light - the specialty assessment consists of performance of corneal light reflex test, cover test, cardinal fields of gaze test, inspection of palpebral conjunctiva, palpation of lacrimal apparatus, inspection of cornea and lens, testing of accommodation of pupils, and use of ophthalmoscope to inspect optic disc, retinal vessels, background, fovea, macula, and anterior chamber

ch. 32 differentiate between general routine screening versus skills needed for focused or specialty assessment of the older adult

- the general routine screening of the older adult requires expertise and experience - the specialty assessment of the older adult involves an in-depth understanding of geriatric syndromes and functional abilities necessary to perform and complete an accurate assessment

ch. 22 differentiate between general routine screening versus skills needed for focused or specialty assessment of the peripheral vascular system

- the general routine screening of the peripheral vascular system includes the observation of arm size and venous pattern, palpation of the client's fingers, hands, arms, temperature, capillary refill time, popliteal pulses, femoral pulses, radial pulses, ulnar pulses, inspection of the legs temperature, distribution of hair, lesions, ulcers, edema, palpation of dorsalis pedal pulses, posterior tibial pulses, and inspection of varicosities and thrombophlebitis - the specialty assessment of the peripheral vascular system consists of the palpation of brachial pulses, Allen test, epitrochlear lymph nodes, superficial inguinal lymph nodes, ausultation of femoral pulses, perform the position change test for arterial insufficiency, determine ankle-brachial index (ABI), and perform manual compression test and Trendelenburg test

ch. 19 differentiate between general routine screening versus skills needed for focused or specialty assessment of the lungs and thorax

- the general routine screening of the thorax and lungs includes the observation of face, lips, chest, use of accessory muscles, and intercostal spaces, inspection of the color and shape of nails, configuration of anterior and posterior thorax, and client's positioning, palpation of the anterior and posterior thorax for tenderness, sensation, surface masses, fremitus, crepitus, and surface characteristics, assessment of anterior and posterior thorax expansion, percussion for tone, and auscultation of normal lung and adventitious breath sounds - the specialty assessment of the thorax and lungs consists of the percussion for diaphragmatic excursion and auscultation of voice sounds

ch. 15 describe the structure and function of the head and neck

- the head consists of the skull, which can be broken down into the cranium and face, cranium houses and protects the brain and major sensory organs, consists of the frontal (1), parietal (2), temporal (2), occipital (1), ethmoid (1), and sphenoid (1) bones, cranial bones are joined together by the sagittal, coronal, squamosal, and lambdoid sutures, face bones give shape to the face, consists of the maxilla (2), zygomatic (2), inferior conchae (2), nasal (2), lacrimal (2), palatine (2), vomer (1), and mandible (1) bones, every facial bone is immovable except for the TMJ, contains many muscles that produce facial movement and expression, temporal artery is located between the eye and top of the ear, parotid glands are located anterior and inferior to the ears, and submandibular glands are located inferior to the mandible - the neck is composed of muscles, ligaments, cervical vertebrae, hyoid bone, major blood vessels, larynx, trachea, and thyroid gland, sternomastoid and trapezius muscles allow movement and provide support to the head and neck, sternomastoid rotates and flexes, trapezius extends and moves, XI cranial nerve is responsible for muscle movement that permits shrugging of shoulders and turning the head against resistance, vertebral prominens is C7 that can easily be palpated when the flexed, internal jugular veins and carotid arteries are located bilaterally to the sternomastoid, external jugular veins lie diagonally over the sternomastoid, thyroid gland is the largest endocrine gland in the body, produces thyroid hormones that increase the metabolic rate, composed of two lateral lobes connected by an isthmus, trachea is the passage through which air enters the lungs, and hyoid bone is attached to the tongue and is under the mandible - the lymph nodes are found in both the head and neck that filter a clear substance composed of excess tissue fluid (lymph), filtering removes bacteria and tumor cells and produces lymphocytes and antibodies as defense, normal lymph nodes are not palpable, but swell and become painful when they are overwhelmed by infection, lymph nodes are located in the preauricular, postauricular, tonsillar, occipital, submandibular, submental, superficial cervical, posterior cervical, deep cervical, and supraclavicular regions

ch. 21 describe the structure and function of the heart and neck vessels

- the heart pumps blood to the lungs for gas exchange (pulmonary circulation) and to all other parts of the body (systemic circulation), composed of the left and right atria, left and right ventricles, AV valves, arteries, veins, endocardium, myocardium, and epicardium - the heart vessels carry blood to and away from the heart (great vessels), return blood to the right atrium from the upper and lower torso (inferior and superior vena cava), carry blood to the lungs (pulmonary artery), return blood back to the heart (pulmonary veins), and transport oxygenated blood to the body (aorta) - the neck vessels supply the head, neck, and brain with oxygenated blood (carotid arteries) and return blood to the heart from the head and neck by the superior vena cava (jugular veins)

ch. 14 review the anatomy and functions of the skin, hair, and nails

- the integumentary system consists of the skin, hair, and nails - skin is the largest organ in the body, a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration, plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, vitamin D synthesis, and provides individual identity, thicker on the palms of the hands and soles of the feet, continuous with the mucous membranes at the orifices, and is composed of the epidermis (outermost layer), dermal, and subcutaneous tissue (innermost layer) - hair consists of layers of keratinized cells, found over much of the body except for the lips, nipples, palms of the hands, soles of the feet, labia minora, and penis, hair develops within a sheath of epidermal cells (hair follicle), the follicle is attached to arrector pili muscles that contract in response to cold or fright, vellus hair (peach fuzz) is short, pale, fine, and present over much of the body, terminal hair (scalp and eyebrows) is longer, darker, and coarser, hair color varies based on the type and amount of pigment production, and hair has a variety of functions such as thermoregulation, protection, insulation, self-expression, and filtration - nails are the hard and transparent plates of keratinized epidermal cells that grow from the cuticle, located on the distal phalanges of the fingers and toes, nail body extends over the entire nail bed, lunula is a crescent-shaped area located at the base, protect the distal ends of digits, enhance precise movement, and allow for an extended precision grip

ch. 26 describe the structure and function of male genitalia, anus, rectum, and prostate

- the male external genitalia consists of the penis and scrotum, the penis functions in reproduction and urination and is composed of the shaft, corpus cavernosa, corpus spongiosum, glans penis, corona, and foreskin if not circumcised, the scrotum functions in protection and maintenance of temperature and is composed of sweat and sebaceous glands, rugae, and cremaster muscle - the male internal genitalia consists of the testes and spermatic cord, the testes function in protection and production of spermatozoa and testosterone and are composed of tunica vaginalis and two testicles, the spermatic cord functions in facilitation of passage for semen and is composed of blood vessels, lymphatic vessels, nerves, and vas deferens - the anus functions in detection and elimination from the digestive system and consists of internal and external sphincters, somatic sensory nerves, anal verge, anorectal junction, columns of Morgagni, arteries, veins, and visceral nerves - the rectum functions in unknown ways and consists of anorectal junction, sigmoid colon, rectal ampulla, valves of Houston, and peritoneum - the prostate functions in promotes sperm motility and neutralization of female acidic vaginal secretions and consists of two lobes, seminal vesicles, and bulbourethral glands

ch. 18 describe the structure and function of the mouth, throat, nose, and sinuses

- the mouth (oral cavity) is formed by the lips, cheeks, hard and soft palates, teeth, gums (gingiva), salivary glands, submandibular glands, sublingual glands, uvula, tongue, and its muscles, begins the digestive tract, masticates food, and serves as an airway for the respiratory tract - the throat (pharynx) is located behind the mouth and nose, serves as a muscular passage for food and air, broken up into the nasopharynx, oropharynx, and laryngopharynx, moves food down the throat, and tonsils help protect against infection - the nose consists of an external portion covered with skin and an internal nasal cavity, composed of bone and cartilage and is lined with a mucous membrane, filters air, smells, takes in air, and warms air - the sinuses consist of the four pairs of paranasal sinuses, frontal are above the eyes, maxillary are in the upper jaw, ethmoidal and sphenoidal are smaller and deeper in the skull, decrease the weight of the skull, and act as resonance chambers during speech

ch. 9 explain the pathophysiology of pain

- the pathophysiologic phenomena of pain are associated with the central and peripheral nervous systems - the source of pain stimulates peripheral nerve endings (nociceptors) that transmit the sensations to the CNS - nociceptors are sensory receptors that detect signals from damaged tissue and chemicals released from the damaged tissue - three types of nociceptors are mechanosensitive (A-delta fibers), sensitive to intense mechanical stimuli (pliers pinching skin), thermosensitive (A-delta fibers), sensitive to intense heat and cold and polymodal (C fibers), and sensitive to noxious stimuli of mechanical, thermal, or chemical nature - distributed throughout the body, skin, subcutaneous tissue, skeletal muscle, joints, peritoneal surfaces, pleural membranes, dura mater, and blood vessel walls

ch. 19 describe the function and structure of the thorax and lungs

- the thorax provides support and protection for many important organs, including those of the lower respiratory system, it is constructed of the sternum, 12 pairs of ribs, 12 thoracic vertebrae, muscles, and cartilage - the lungs facilitate respiration that maintains an adequate oxygen level in the blood to support cellular life, they are two cone-shaped, elastic structures suspended within the thoracic cavity with the apex slightly above the clavicle and the base at the level of the diaphragm

ch. 4 describe the significance and process for validation of client data

- validation of client data is crucial to the first step of the nursing process and prevents premature closure of the assessment and collection of inaccurate data - ways to validate data includes rechecking your own data, clarifying data with the client, verifying data with another health care professional, and comparing objective and subjective findings to look for discrepancies

ch. 2 describe effective verbal and nonverbal communication techniques to collect subjective client data

- verbal communication consists of open ended questions, closed ended questions, laundry list, rephrasing, well placed phrases, inferring, and providing information - nonverbal communication includes appearance, demeanor, facial expressions, attitude, silence, and listening

ch. 3 explain how to prepare oneself, the physical environment, and the client for a physical examination

- wash your hands before and after the examination, always wear gloves, use a new pin to assess, and wear a mask and protective eye goggles - set up in a private area at a comfortable room temperature, free of distractions, with adequate lighting, table at an appropriate height, and a bedside tray - inspect, palpate, percuss, and auscultate the patient, find any deviations, ask the client more questions to validate or obtain more information, focus the physical assessment, validate findings with an instructor, and refer the client to next level care

ch. 17 correctly use the otoscope to inspect the auditory canal and tympanic membrane

- when using an otoscope a child one year or younger, pull the ear down and back - when using an otoscope for children older than one and adults, pull the ear up and back - during the inner ear examination, have the patient sit up straight, lean slightly away, get the largest speculum for the ear, pull ear appropriately, hold the otoscope against the client's face, brace your hand, insert speculum down and in a half inch, and look through

ch. 2 describe how to use a genogram to illustrate a client's family health history

a genogram shows a graphic representation of a family tree that displays detailed data on relationships among individuals

ch. 13 communicate interview and assessment findings of the client's nutrition, hydration, and food safety practices through clear concise documentation and verbal reports

SBAR, nutritional screening, nutrition history form, and 24 hour diet recall are a few examples of documentation for client's nutrition

ch. 2 describe the process for performing a review of systems

address each body system by paying attention to skin, hair, nails, head, neck, ears, eyes, mouth, throat, nose, sinuses, thorax, lungs, breasts, regional lymphatics, heart vessels, neck vessels, peripheral vascular, abdomen, male/female genitalia, anus, rectum, prostate, musculoskeletal, and neurologic

ch. 28 correctly perform a total integrated head-to-toe physical assessment, identifying normal and abnormal findings

an integrated head-to-toe assessment should include general survey, mental status examination, skin, head and face, eyes, ears, nose and sinuses, mouth and throat, neck, arms, hands and fingers, posterior and lateral chest, anterior chest, breasts, heart, abdomen, legs, feet and toes, musculoskeletal, neurologic, and genitalia

ch. 31 interview children, adolescents, and their parents or caregivers as appropriate for an accurate nursing history

ask the child or adolescent about their name, caregivers' names, primary healthcare provider, last well-child care appointment, address, residence, parents' marital status, parents' ages, child's age, child's date of birth, adopted, foster, or natural, ethnic origin, religion, parents' occupation, reason for seeking healthcare, current health concern, location of pain or symptom, pain scale using Wong-Baker FACES pain rating, planned pregnancy, prenatal care, health during pregnancy, problems with pregnancy, tobacco, alcohol, or drug use, general state of health, chronic illnesses, allergies, prescription medications, devices, treatments, immunizations, family history of chronic diseases, ages and causes of blood relatives' deaths, family members with communicable diseases, school or after school activities, typical diet, sexual activity, screen time, changes in hair texture, scalp itching, changes in nails, exposure to contagious diseases, rashes or sores, acne, excessive bruising or burns, cosmetics, tattoos, pierced body parts, head injury, headaches, swollen neck glands, neck stiffness, crossed eyes, rubbing or blinking of eyes, straining or squinting to see distant objects, vision testing, glasses or contact lenses, paying attention, speaking and age begun, listening to loud music, hearing aid, ear infections, tubes in ears, hearing testing, difficulty swallowing or chewing, strep throat, tonsillitis, pharyngitis, mouth or throat infections, teeth eruption, dental problems, last dentist visit, dentures, nosebleeds, sinus problems, cough, wheezing, shortness of breath, nocturnal dyspnea, influenza and pneumonia vaccines, smoking, developing breasts, abnormal breast development, chest pain, heart murmurs, congenital heart disease, hypertension, fatigue, difficulty keeping up, fainting, turning blue, meeting normal growth requirements, bluing of extremities, fingers and toes getting colder, blood clotting problems, vomiting, abdominal pain, digestive problems, trauma to abdomen, hernias, urination, age of toilet training, frequency of urinating, burning or pain during urination, masturbation concerns, sexual abuse, age of puberty, thelarche, and menarche, wet dreams, source of sex education, performing breast or testicular self-examinations, menstruation, sexual history, information about HPV, pap smear, pain or discomfort with intercourse, sexual partners, types of contraception, condoms, sexually transmitted infections, prior pregnancies and results, gynecologic examinations, bowel movements, history of bleeding, constipation, diarrhea, rectal itching, or hemorrhoids, limited range of motion, joint pain, stiffness, paralysis, bone deformities, fractures, corrective devices, posture, sports involvement, protective gear, learning disabilities, attention problems, problems with memory, seizure, head injury, and problems with motor coordination

ch. 23 interview a client for an accurate nursing history of the client's abdomen and related functions of the organs within the abdomen

ask the client about abdominal pain, indigestion, nausea, vomiting, increase or decrease in appetite, stools per day, color and consistency of stools, constipation, diarrhea, yellowing of skin or whites of eyes, itchy skin, dark urine, personal history of gastrointestinal disorders, urinary tract diseases, viral hepatitis (A, B, or C), abdominal surgery, trauma, prescription or over-the-counter medications, family history of gastrointestinal cancer, alcohol consumption, typical diet, caffeine intake, exercise habits, and stress

ch. 22 interview a client for an accurate nursing history of the peripheral vascular system

ask the client about any changes in color, temperature, or texture of the skin, pain or cramping in the legs, pain with walking, climbing stairs, pain in the middle of the night, heaviness, aches in the legs, bulging or contorted leg veins, sores, open wounds, edema in legs or feet, swollen glands or lymph nodes, unusual sexual activity, past problems with arm and leg circulation, heart or blood vessel surgeries, treatments, family history of DVT, diabetes, hypertension, coronary heart disease, intermittent claudication, elevated cholesterol, or elevated triglycerides, smoking tobacco, exercising regularly, oral or transdermal contraceptives, stress, current problems with arm and leg circulation, leg ulcers, varicose veins, medications, and support hose

ch. 15 interview the client for an accurate nursing history of his or her head and neck

ask the client about any neck pain, headaches, difficulty moving head and neck, lumps or lesions that do not heal, experience of dizziness or loss of consciousness, change in texture of skin, hair, or nails, changes in energy level or sleep habits, emotional stability, weakness or numbness in face, arms, or legs, previous head or neck problems, treatment and its results, current medications, family history of head cancer, neck cancer, or migraines, smoking or chewing tobacco, using alcohol or recreational drugs, wearing protective gear, kinds of recreational activities, typical posture, and relationship problems caused by head or neck injuries

ch. 21 interview a client for an accurate nursing history of the heart and neck vessels

ask the client about chest pain, fast heart beats, skipping beats, extra beats, fatigue, easily tiring, dyspnea, shortness of breath, coughing up mucus, dizziness, nocturia, edema in feet, ankles, or legs, frequent heartburn, history of heart defect, murmur, rheumatic fever, heart surgeries, cardiac balloon interventions, last electrocardiogram, lipid profile, medications, treatments, monitoring heart rate or blood pressure, family history of hypertension, myocardial infarctions, coronary heart disease, elevated cholesterol, or diabetes mellitus, smoking habits, stress, typical diet, drinking alcohol, exercise, daily activities, effect on sexual activity, pillows to sleep at night, and fears about heart disease

ch. 19 interview a client for an accurate nursing history of the thorax and lungs

ask the client about difficulty breathing, shortness of breath, chest pain, cough, sputum, wheezes, gastrointestinal symptoms, heartburn, frequent hiccups, prior respiratory problems, thoracic surgery, biopsy, trauma, allergies, medications for breathing problems, chest x-ray, tuberculosis skin test, influenza immunization, travel outside of the US, family history of lung disease, secondhand smoke exposure, pulmonary illnesses or disorders, dietary intake, smoking cigarettes, using tobacco, environmental conditions, difficulty performing ADL, and herbal medicines or alternative therapies

ch. 25 interview a client for an accurate nursing history of the neurologic system

ask the client about headaches, seizures, loss of control over bladder, current medications, safety precautions, dizziness, lightheadedness, problems with balance and coordination, clumsy movements, numbness, tingling, decrease in ability to smell or taste, tinnitus, hearing loss, change in vision, difficulty understanding, dysarthria, dysphagia, difficulty swallowing, muscle weakness, loss of movements, repetitive involuntary trembling, quivering, or shaking, memory loss, head injury with or without loss of consciousness, physical or mental changes, meningitis, encephalitis, injury to the spinal cord, stroke, family history of high blood pressure, stroke, Alzheimer disease, dementia, epilepsy, brain cancer, or Huntington chorea, alcohol intake, recreational drug use, smoking, seatbelt, protective headgear, 24-hour diet recall, prolonged exposure to lead, insecticides, pollutants, or chemicals, lift heavy objects, perform repetitive motions, normals independent ADLs, view of self, and stress

ch. 27 interview a client for an accurate nursing history of the female genitalia, anus, and rectum

ask the client about last menstrual period, symptoms before or during period, age of first period, irregular or missed periods, change in period, symptoms of menopause, hormone-replacement therapy regimen, concerns about menopause, change in color, amount, or odor of vaginal discharge, pain or itching in genital or groin area, lumps, swelling, or masses in genital area, problems with sexual activity pattern, problems with fertility, difficulty urinating, control over urine, usual bowel pattern, pain when urinating or passing a bowel movement, constipation, diarrhea, nausea, vomiting, control over bowels, color and form of stools, blood or mucus in stools, itching or pain in rectal area, prior gynecologic problems, last pelvic or rectovaginal examination, last pap smear, prior diagnosis of an STI, prior pregnancies, miscarriages or abortions, diabetes, anal or rectal trauma, congenital deformities, hemorrhoids, fecal occult blood test, sigmoidoscopy, colonoscopy, smoking, number of sexual partners, contraceptives, genital problems, sexual preference, current sexual activity, concerns about sexual orientation, anal sex, communication about sex, fears about sex, concerns with fertility, monthly genital self-examinations, anticipations for menopause, test for HIV, toxic shock syndrome, SZTIs and their prevention, cotton underwear, tight jeans, wiping from front to back, use of douche, laxatives, stool softeners, enemas, or bowel-enhancing medications, high-fiber and saturated fat foods, regular exercise, and calcium supplements

ch. 20 interview a client for an accurate nursing history of the breasts and axillary lymph nodes

ask the client about lumps, swelling, redness, warmth, dimpling, rashes, change in size or firmness, breast pain, prior breast disease, age of menstruation, age of menopause, children, first and last day of menstrual cycle, family history of breast cancer, hormones, contraceptives, antipsychotic agents, exposure to radiation, benzene, or asbestos, diet, alcohol consumption, caffeine consumption, exercise habits, physical appearance, and breast self-examinations

ch. 6 interview and assess a client's mental status history and risk for substance abuse

ask the client about name, address, telephone number, age, date of birth, gender, marital status, educational level, employment, health concern, reason for seeking healthcare, headaches, trouble breathing, heart palpitations, insomnia, irritability, mood swings, fatigue, suicidal thoughts, violent thoughts, previous medical treatments, previous hospitalizations, counseling, head injury, meningitis, encephalitis, stroke, active duty in the armed forces, family history of mental health problems, typical day routine, effect on ADLs, energy level, usual eating habits, bowel elimination patterns, sleep habits, exercise regimens, caffeinated beverages, prescribed or OTC medications, alcohol, tobacco, recreational drugs, environmental toxins, religious affiliations, self-esteem, relationships with others, support systems, role in the family, current life stressors, and thoughts about future

ch. 26 interview a client for an accurate nursing history of the male genitalia, anus, rectum, and prostate

ask the client about pain in their penis, scrotum, testes, or groin, itching in pubic area, lesions on penis or genital area, burning or stinging, penis discharge, lumps, swelling, or masses in scrotum, genital, or groin area, change in scrotum size, heavy and dragging feeling, difficulty urinating, times urinating during the night, new medications, change in color, odor, or amount of urine, pain or burning while urinating, urinary incontinence, dribbling, change in sexual activity or desire, difficulty attaining an erection, trouble with fertility, usual bowel pattern, constipation, diarrhea, nausea, vomiting, trouble controlling bowels, mucus in stool, oily or greasy stools, itching or pain in rectal area, prior medical problems, prior treatments and results, last testicular examination, test for human immunodeficiency virus, chlamydia, gonorrhea, trichomoniasis, hepatitis, or syphilis, anal or rectal trauma, congenital deformities, prostate surgery, hemorrhoids, blood in stool, sigmoidoscopy, colonoscopy, last digital rectal examination, level of prostate-specific antigen in blood, family history of polyps or cancer, number of sexual partners, birth control method, satisfaction with sexual functioning, concerns about fertility, current sexual activity, fears about sex, communication about sex, STIs and their prevention, exposure to chemicals or radiation, use of laxatives, stool softeners, enemas, or bowel movement-enhancing medications, anal sex, prostate medications, high-fiber and saturated fat foods, regular exercise, and effect on activities of daily living

ch. 17 interview a client for an accurate nursing history of hearing and the ears

ask the client about recent changes in hearing, ability to hear well, sounds being affected, ear drainage, ear pain, dizziness or unbalance, previous ear problems, past ear treatments, family history of hearing loss, working or living in an area with frequent loud noise, time spent swimming, hearing loss affecting self care or relationships with others, last hearing examination, hearing aid, and hygiene of cleaning ears

ch. 16 interview a client for an accurate eye and vision nursing history

ask the client about recent visual difficulties or changes in vision, spots or floaters in vision, blind spots, halos or rings around lights, trouble seeing at night, double vision (diplopia), eye pain or itching, redness or swelling, excessive watering or tearing, any eye discharge, problems with eyes or vision, previous eye surgery, past treatments, current medications, last eye examination, testing for macular degeneration, prescription for corrective lenses, testing for glaucoma, family history of eye problems or vision loss, exposure to conditions or substances that may harm eyes or vision, wearing sunglasses during exposure to sun, any vision loss, using visuals aids to assist in seeing, and typical diet

ch. 24 interview a client for an accurate nursing history of the musculoskeletal system

ask the client about recent weight gain, difficulty chewing, joint, muscle, or bone pain, stiffness, swelling, or limitation of movement, past problems or injuries, treatments, aftereffects, last tetanus and polio immunizations, diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, osteoporosis, menopause, estrogen or hormone replacement therapy, family history of rheumatoid arthritis, gout, or osteoporosis, exercise, diet, medications, smoking tobacco, consuming alcohol or caffeine, typical 24-hour diet, calcium supplements, activities of daily living, occupation, posture at work and leisure, special footwear, difficulty moving, assistive devices, interference with socializing or sexual activity, stress, and bone density screening

ch. 13 interview a client for an accurate nursing history of his or her nutritional status, hydration, food safety practices, and food allergies

ask the client about their height and weight, recent changes in weight, diet or dietary restrictions, fluid intake especially water, 24 hour dietary recall, changes in appetite, recent occurrences of vomiting, diarrhea, or constipation, food allergies or intolerances, chronic illnesses, recent trauma, surgery, or serious illness, current medications, any obese relatives, family members with chronic illnesses, religious or cultural beliefs, preparation of meals, method of storing, cooking, and serving food, how many times meals are eaten at home and out, what types of food are usually purchased, and exercise regimen

ch. 8 interview the client for an accurate survey of his or her general health status and vital signs

ask the client about their name, address, telephone number, email address, age, present health concerns, high fevers, alterations to heartbeat, difficulty breathing, pain (using the COLDSPA method), blood pressure, slow or fast heartbeat, medications, allergies, family history (heart disease, diabetes, thyroid disease, lung disease, high blood pressure, or cancer), educational background, employment, satisfaction of life, health care, tobacco/alcohol/drug use, dietary habits, and exercise routine

ch. 2 identify the major categories of a complete client health history

biographical data, reasons for seeking health care, history of present health concern, personal health history, family health history, ROS for current health problems, lifestyle and health practices profile, and developmental level

ch. 8 correctly perform an accurate general survey

carry out a survey by observing physical development, body build, fat distribution, gender, sexual development, apparent age, reported age, skin condition, skin color, posture, and gait

ch. 14 interview clients for an accurate nursing history of the skin, hair, and nails

ask the client about their skin, hair, and nails by asking them about current skin problems, what aggravates it, what relieves it, any birthmarks or moles, change in the ability to feel pain, pressure, touch, or temperature, experience of pain, itching, tingling, or numbing, any medications being taken, control over body odor, excessive sweating, hair loss, change in the condition of hair, change in the appearance of nails, severe sunburns, previous problems with skin, hair, or nails, any treatment or surgery related, recent hospitalizations, allergic skin reactions to food, medications, or environmental substances, recent viral or bacterial illness, pregnancy or menstrual periods, history of self-injury, recent family illnesses, relatives with skin cancer or keloids, sunbathing, using sunblock, performing a skin self-examination once a month, exposure to chemicals or irritants, long periods of time sitting or lying down, exposure to extreme temperatures, body piercings or tattoos, daily routine for skin, hair, and nail care, kinds of foods and fluids consumed in a day, history of smoking and/or drinking alcohol, limitations of skin problems, relationship problems due to disorder, and type and amount of stress felt

ch. 18 interview the client for an accurate nursing history of the mouth, throat, nose, and sinuses

ask the client about tongue or mouth sores or lesions, redness, swelling, bleeding, or pain of the gums or mouth, toothaches, pain over sinuses, nosebleeds, frequent drainage from nose, breathe through both nostrils, change in ability to smell or taste, difficulty swallowing, sore throat, previous oral, nasal, or sinus surgery, history of sinus infections, seasonal environmental allergies, current treatments or medications, family history of mouth, throat, nose, or sinus cancer, smoke or use smokeless tobacco, drink alcohol, grind teeth, dental care, last dental examination, braces, avoid certain types of food, dentures, brushing techniques, sun exposure, use lip sunscreen products, and usual dietary intake

ch. 33 interview and assess a family for structure, development, and function

ask the family about internal family structure, family composition, gender roles, rank order, subsystems, boundaries, family power structure, external family structure, extended family, external systems, context, family development, lifecycle stages, family function, instrumental function, affective and socialization function, expressive function, verbal communication, nonverbal communication, circular communication, family's healthcare function, and multigenerational patterns

ch. 30 complete a newborn history by interviewing parents about their newborn's prenatal development and by reviewing prenatal and delivery records

ask the newborn's parents about the infant's name, caregivers' names, primary healthcare provider, last well-child care appointment, address, residence, parents' marital status, parents' ages, infant's age, date of birth, adopted, foster, or natural, ethnic origin, religion, parents' occupations, reason for seeking healthcare, current health status, general state of health, chronic illness, mother's pregnancy, prenatal care, problems with pregnancy, accidents during pregnancy, medications during pregnancy, tobacco, alcohol, and drug use, delivery of newborn, location of newborn's birth, type of delivery, anesthesia, type of birth, complications, Apgar score at 1 and 5 minutes, weight, length, and head circumference at birth, problems after birth, hospitalizations, major illnesses, immunizations, allergies, prescriptions, devices, treatments, chronic health conditions in the family, genogram of two generations, family members with communicable diseases, breast or bottle-fed, food and fluid consumption, sleep patterns, sleeping position, changes in hair texture, scaling on scalp, exposure to contagious diseases, rashes, sores, diaper rash, excessive bruising, burns, birthmarks, head injury, fontanelles, head control, unusual eye movements, crossing of eyes, blinking, focusing on moving objects, cloudy pupils, turning to human voice, response to loud noises, ear infections, tubes in ears, second-hand smoke, teeth, day care, cough, wheezing, shortness of breath, grunting, nasal flaring, chest retractions, frequent or severe colds, fatigue, bluing of extremities, skin, lips, or nail beds, vomiting, abdominal pain, urination, diapers changed per day, diaper rash, bowel movements, bleeding, constipation, diarrhea, hemorrhoids, limited range of motion, joint pain, stiffness, paralysis, fractures, bone deformities, seizure, and problems with motor coordination

ch. 32 interview the older adult for an accurate nursing history

ask the older client about changes in ability to concentrate or think clearly, mental status with SLUMS and CAM, changes in memory, purpose in life, activities or interests, depression, anger or inability to control emotions, basic self-care activities, ability to achieve wellbeing and perform ADLs, stumbles or falls, assistive devices, lightheadedness or dizziness, difficulty standing up, discomfort in legs, pain, cramping, aching, fatigue, weakness, shortness of breath, faster breathing, sweating, anorexia, recurrent cough, cough with blood, tobacco use, weight loss, chronic cough, pneumococcal vaccine, annual flu vaccines, change in appetite, nausea, vomiting, medications, 24-hour diet recall, malnutrition, dentures, problems with teeth, feeling of choking, fluid intake, urine leakage, problems controlling or starting urine flow, nighttime urinating, dribbling, bowel elimination, problems with bowel habits, stool with blood, discomfort, aching, soreness, problems that require hands, arms, backs, or legs, and pain scale from 0-10

ch. 8 assess accurate vital signs

assess vitals by measuring temperature (tympanic, oral, axillary, temporal, or rectal), measuring radial pulse rate, evaluating pulse rhythm, assessing pulse amplitude and contour, palpating arterial elasticity, monitoring respiratory rate, observing respiratory rhythm and depth, and noting comfort level

ch. 28 differentiate between the skills needed to complete an integrated head-to-toe routine screening versus those needed for a focused or specialty assessment of a specific body system

assessment of every system should be completed in the integrated head-to-toe assessment

ch. 30 perform an initial physical assessment of the newborn using the correct techniques

assign Apgar scores at 1 and 5 minutes after delivery, monitor axillary temperature, inspect and auscultate lung sounds, monitor respiratory rate, auscultate apical pulse, weigh the newborn scale, measure length, measure head circumference, measure chest circumference, assess neuromuscular maturity in supine position, assess for physical maturity, determine score rating, assess newborn reflexes, observe general appearance, screen for cognitive, language, social, and gross and fine motor development, assess rectal temperature, note apical pulse rate, assess respiratory rate and character, evaluate infant blood pressure, evaluate newborn blood pressure, measure length, measure weight, determine head and chest circumference, assess for skin color, odor, and lesions, palpate for texture, temperature, moisture, turgor, and edema, inspect and palpate hair, inspect and palpate nails, inspect and palpate the head, test head control, head posture, and range of motion, inspect and palpate the face, inspect and palpate the neck, inspect the external eye, perform visual acuity tests, perform extraocular muscle tests, perform ophthalmoscopic examination, inspect external ears, inspect internal ear, test hearing acuity, inspect mouth and throat, inspect nose and sinuses, inspect the shape of the thorax, observe respiratory effort, percuss the chest, auscultate for breath and adventitious sounds, inspect and palpate breasts, inspect and palpate the precordium, auscultate heart sounds, inspect the shape of the abdomen, inspect umbilicus, auscultate bowel sounds, palpate for masses and tenderness, palpate liver, palpate spleen, palpate kidneys, palpate bladder, inspect penis and urinary meatus, inspect and palpate scrotum and testes, inspect and palpate inguinal area for hernias, inspect external genitalia, assess arms, hands, feet, and legs, assess for congenital hip dysplasia, assess spinal alignment, assess joints, assess muscles, test deep tendon and superficial reflexes, and test motor function

ch. 4 discuss situations that require client data to be rechecked or verified

client data would need to be rechecked or verified when there are discrepancies or gaps between the subjective and objective data, discrepancies or gaps between what the client says at one time and another, and findings that are highly abnormal and/or inconsistent with other findings

ch. 1 describe which phases of the nursing process involve assessment by the nurse

collection of subjective data, collection of objective data, validation of data, and documentation of data

ch. 32 describe the common structural changes brought on by aging in the various body systems

common structural changes from aging are difficulty hearing, decreased vision, cognitive impairment, difficulty with ambulation and self-care, assisted living, loss of function, strength, and physiologic reserve, depression, immobility, decreased strength and endurance, poor nutrition, fatigue, decreased skeletal muscle mass, increased body fat, decreased metabolism, less toleration to cold, weight gain, decreased lung capacity and kidney function, and lower resistance to illness

ch. 15 discuss risk factors associated with head and neck disorders across the cultures

cultural norms for touch differ for assessing the head, some cultures (such as Southeast Asian) prohibit touching the head or touching the feet before touching the head, variations of facial structures and features vary among individuals and cultures, some risk factors include injury to head and neck related to poor posture, not wearing protective devices when appropriate, ineffective health maintenance (due to smoking, drug use, nutrition, body image, and refusing protective wear), chronic pain, and impaired swallowing

ch. 18 describe cultural variations in assessment findings of the mouth, throat, nose, and sinuses

cultural variations in assessing the mouth, throat, nose, and sinuses include periodontal disease varies in prevalence and severity by ethnic group, blacks have a three times higher risk than whites, pink lips are normal in light-skinned client, as are bluish or freckled lips in some dark-skinned clients, number of tooth variations, especially in Asian, Pacific Islanders, and Native Americans as well as talon cusps on incisors and circular cusps on molars, buccal mucosa should appear pink in light-skinned clients, tissue pigmentation typically increases in dark-skinned clients, freckling or dark pigmentation on ventral surface of tongue and floor of mouth, hard and soft palate may also be darkly pigmented, bony protuberance in the midline of the hard palate (torus palatinus), tori palatinus and tori mandibular tend to occur more in Native Americans, Eskimos, and women, more prevalent in whites than blacks, and Native Americans and Asians may have a split (bifid) uvula

ch. 28 explain how to prepare yourself and the client for a holistic nursing interview and head-to-toe integrated physical examination

discuss the purpose and importance of the health history and physical assessment with your client, obtain client's permission to ask personal questions and perform the various physical assessments, explain your respect for the client's privacy and confidentiality, respect the client's right to refuse any part of the assessment, and explain that the client will need to change into a gown for the examination

ch. 4 describe the multiple purposes of accurate and timely documentation of client data

documenting client data is crucial to promoting effective communication among multidisciplinary health team members to facilitate safe and efficient client care, providing the health care team with a database that becomes the foundation for care of the client, identifying health problems, formulating nursing diagnoses, and planning immediate and ongoing interventions

ch. 28 list all the equipment needed for a total physical examination

equipment needed for the integrated head-to-toe assessment are the assessment documentation forms, balance beam scale with height attachment, flexible tape measure, skin-fold calipers, stethoscope, sphygmomanometer, thermometer, watch with second hand, gloves, mirror, magnifying glass, penlight, ruler with centimeter markings, skin marking pen, stethoscope, small cup of water, cover card, gloves, newspaper print, Rosenbaum pocket screener, ophthalmoscope, penlight, Snellen chart, otoscope, tuning fork, watch with second hand, gauze pad, penlight, otoscope, tongue depressor, client gown, draping sheet, gloves, mask, metric ruler, skin marking pen, stethoscope, client gown, Doppler ultrasound device, conductivity gel, flexible metric tape measure, gauze, skin marking pen, sphygmomanometer, stethoscope, tourniquet, watch with second hand, client drape, metric ruler, skin marking pen, small pillows, stethoscope, flexible metric tape measure, goniometer, newsprint, ophthalmoscope, penlight, Snellen chart, cotton-tipped applicators, flexible metric tape measure, sterile cotton ball, substances to smell or taste, test tubes with hot and cold water, tongue depressor, tuning fork, objects to feel, reflex (percussion) hammer, gloves, water-soluble lubricant, flashlight, specimen card, gloves, light, mirror, vaginal speculum, water-soluble lubricant, bifid spatula, endocervical broom, large swabs, specimen container, pH paper, and feminine napkins

ch. 2 explain types of communication to avoid in the client interview

excessive or insufficient eye contact, distraction, distance, standing, biased or leading questions, rushing through the interview, and reading the questions

ch. 2 describe ways to adapt the interview for the client with emotional issues

explain who you are, ask simple questions, avoid becoming anxious, approach in a calm manner, allow them to vent feelings, obtain help from health care professionals, keep yourself between the client and door, express interest, respond in a neutral manner, and encourage them

ch. 33 define family

family refers to two or more individuals who depend on one another for emotional, physical, and economic support, the family is whoever they say they are

ch. 6 use the Glasgow Coma Scale to assess one's level of consciousness (response to stimuli) when at high risk for deterioration of the nervous system

the Glasgow Coma Scale is scored from 3-15 (11-15 being normal and below 7 with those in a coma) and is used to assess the patient's response to stimuli with eye-opening response, most appropriate verbal response, and most integral motor response (usually with the arm)

ch. 3 survey the various pieces of equipment needed to perform a physical examination

gloves, gown, sphygmomanometer, stethoscope, thermometer, watch, pain rating scale, tape measure, pen light, mirror, magnifying glass, Snellen E chart, opaque card, ophthalmoscope, tuning fork, otoscope, tongue depressor, pillows, goniometer, cotton-tipped applicators, substances to smell and taste, objects to feel, percussion hammer, cotton ball, paper clip, specimen card, lubricant, spatula, broom, and swabs

ch. 1 describe the steps of the analysis phase of the nursing process

identify the abnormal data and strengths, cluster the data, draw inferences and identify problems, propose possible nursing diagnoses, check for defining characteristics of those diagnoses, and document conclusions

ch. 1 describe what the nurse's role in assessment may be 25 years from now

in the future, nurses will need increased acuity for complexity of care needs, use technology and online retrieval of data, and deal with health challenges that require assessment skills

ch. 14 use correct techniques to perform a physical assessment of the skin, hair, and nails

inspect general skin coloration and color variations, note odors emanating from the skin, assess skin integrity, inspect for lesions, palpate skin to assess texture, thickness, moisture, temperature, turgor, and edema, inspect scalp and hair for color and condition, amount and distribution of scalp, body, axillae, and pubic hair, nail grooming and cleanliness, nail color and markings, and shape of nails, palpate nail to assess texture and consistency, and test capillary refill in nail beds by pressing the nail tip briefly and watching for color change

ch. 19 perform a physical assessment of the thorax and lungs using the correct techniques of inspection, auscultation, palpation, and percussion

inspect nasal flaring, pursed lip breathing, color of face, lips, and chest, color and shape of nails, posterior thorax configuration, use of accessory muscles, client's positioning, palpate tenderness and sensation, crepitus, surface characteristics, fremitus, observe posterior chest expansion, percuss tone, diaphragmatic excursion, auscultate breath sounds, adventitious sounds, voice sounds, inspect anterior thorax shape and configuration, position of sternum, sternal retractions, slope of ribs, quality and pattern of respiration, intercostal spaces, use of accessory muscles, palpate tenderness, sensation, surface masses, costochondral junction of ribs, crepitus, lesions, fremitus, observe anterior chest expansion, percuss tone, and auscultate breath sounds, adventitious sounds, and voice sounds

ch. 20 perform a physical assessment of the breasts and axillary lymph nodes using the correct techniques

inspect size and symmetry, color and texture, superficial venous pattern, areolas, nipples, retraction, dimpling, axillae, palpate texture, elasticity, tenderness, temperature, masses, nipples, mastectomy and lumpectomy site, inspect axillae, palpate axillae, and ask the client if they know how to perform a BSE

ch. 17 perform a physical assessment of the ears and hearing ability using the correct techniques

inspect the auricle, tragus, and lobule, palpate the auricle and mastoid process, inspect the external auditory canal and tympanic membrane, perform the whisper test, and perform Weber test (tuning fork on the forehead), Rinne test (tuning fork behind and in front of the ear), or Romberg test (client stands with eyes closed) if additional testing of hearing is needed

ch. 26 understand and discuss the physical assessment of male genitalia, anus, rectum, and prostate using the correct techniques

inspect the base of the penis and pubic hair, inspect the skin of the shaft, palpate the shaft, inspect the foreskin, inspect the glans, palpate for urethral discharge, inspect the size and shape of the scrotum, inspect the scrotal skin, palpate the scrotal contents, perform transillumination, inspect for inguinal and femoral hernia, palpate for inguinal hernia and inguinal nodes, palpate inguinal lymph nodes, palpate for femoral hernia, inspect the perianal area, inspect the sacrococcygeal area, palpate the anus, palpate the rectum, palpate the peritoneal cavity, and inspect the stool

ch. 15 use the correct technique to perform a physical assessment of the head and neck

inspect the head and any involuntary movement, palpate the head, inspect the face, palpate the temporal artery and temporomandibular joint, inspect the neck, movement of the neck structures, cervical vertebrae, and range of motion, palpate the trachea and thyroid gland, auscultate the thyroid only if enlarged, and palpate the lymph nodes (starting with preauricular and ending with posterior axillary)

ch. 18 use correct techniques to assess the mouth, throat, nose, and sinuses

inspect the lips, teeth, gums, buccal mucosa, Stensen (parotid) ducts, tongue, palpate the tongue, assess the ventral surface of the tongue, inspect for Wharton ducts, observe the sides of the tongue, check the strength of the tongue and anterior tongue's ability to taste, inspect the hard (anterior) and soft (posterior) palates and uvula, note odor, assess the uvula, inspect the tonsils and posterior pharyngeal wall, check patency of air flow through the nostrils, inspect the internal nose, palpate the sinuses, and percuss the sinuses

ch. 27 understand and discuss the physical assessment of the female genitalia, anus, and rectum, using the correct techniques

inspect the mons pubis, observe and palpate the inguinal lymph nodes, inspect the labia majora and perineum, inspect the labia minora, clitoris, urethral meatus, and vaginal opening, palpate Bartholin glands, palpate the urethra, inspect the size and angle of the vaginal opening, inspect the vaginal musculature, inspect the cervix, inspect the vagina, palpate the vaginal wall, palpate the cervix, palpate the uterus, palpate the ovaries, inspect the perianal area, inspect the sacrococcygeal area, palpate the anus, palpate the rectum, and palpate the cervix through the anterior rectal wall

ch. 4 identify safe guidelines for documentation of client data

keep confidential all documented information in the client record, document legibly or print neatly in non-erasable ink, use correct grammar and spelling, use only abbreviations that are acceptable and approved by the institution, avoid wordiness that creates redundancy, use phrases instead of sentences to record, record data findings and not how they were obtained, write entries objectively, record the client's understanding and perception of problems, avoid recording the word normal for normal findings, record complete information and details for all client symptoms or experiences, include additional assessment content when applicable, and support objective data with specific observations obtained during the physical examination

ch. 32 perform a physical assessment of the older adult using the correct techniques

measure and record the client's height and weight, review laboratory test values, evaluate hydration status, inspect and palpate skin lesions, inspect and palpate hair and scalp, inspect head and neck for symmetry and movement, inspect gums and buccal mucosa for color and consistency, examine the tongue, test gag reflex, inspect the nose for color and consistency, evaluate the sense of smell, palpate the frontal and maxillary sinuses, inspect eyes, eyelids, eyelashes, and conjunctiva, inspect the pupils, ask client about small specks or clouds that move across the field of vision, inspect the external ear, perform an otoscopic examination to determine quantity, color, and consistency of cerumen, inspect the shape of thorax, note respiratory rate, rhythm, and quality of breathing, percuss lung tones, auscultate lung sounds, measure blood pressure, measure activity tolerance, determine adequacy of blood flow, auscultate the carotid, abdominal, and femoral arteries, evaluate arterial and venous sufficiency of extremities, auscultate heart sounds, inspect skin under breasts, determine absorption or retention problems from receiving enteral feedings, palpate the bladder, assess cough while in the lithotomy position, perform a pelvic examination, observe and palpate for inguinal swelling or bulges suggestive of hernia in the same manner as for a younger male, inspect the anus and rectum, palpate the prostate in the male client, observe the client's posture and gait, inspect the general contour of limbs, trunk, and joints, test range of motion and bilateral resistance of joints, assess hip joint for strength and ROM, inspect client's muscle bulk and tone, observe for tremors and involuntary movements, and test sensation to pain, temperature, touch position, and vibration

ch. 6 discuss how both mental health and mental disorders affect your mental status

mental status refers to a client's level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning (feelings, mood, behaviors, stability), consisting of mental health and mental disorders, mental health affects status through economic and social factors, unhealthy lifestyle choices, exposure to violence, personality factors, spiritual and cultural factors, changes in the structure and function of the neurologic system, and psychosocial development level, mental disorders influence status by affecting body systems when prompt assessment and intervention is delayed

ch. 31 perform a physical assessment of children and adolescents using the correct techniques

note overall appearance of the child, screen for cognitive, language, social, and gross and fine motor developmental delays, assess temperature, assess pulse rate, assess respiratory rate, evaluate blood pressure, measure height, measure weight, measure head circumference (HC) or occipital frontal circumference (OFC), observe skin color, odor, and lesions, palpate for texture, temperature, moisture, turgor, and edema, inspect and palpate hair, inspect and palpate nails, inspect and palpate the head, test head control, head posture, and ROM, inspect and palpate the face, inspect and palpate the neck, note the condition of the lips, palates, tongue, and buccal mucosa, observe the condition of the teeth and gums, note the condition of the throat and tonsils, inspect nose and sinuses, palpate the sinuses in older children if sinusitis is suspected, inspect the external eye, perform visual acuity tests, perform extraocular muscles tests, perform the cover test, perform the Hirschberg test, inspect the internal eye, inspect external ears, inspect internal ear, test hearing acuity, percuss and auscultate the lungs, inspect and palpate breasts, inspect and palpate the precordium, inspect the shape of the abdomen, inspect umbilicus, auscultate bowel sounds, palpate liver, palpate spleen, palpate kidneys, palpate bladder, inspect and palpate inguinal area for hernias, assess sexual development, inspect external genitalia, inspect internal genitalia, inspect the anus, assess feet and legs, assess spinal alignment, assess gait, assess joints, assess muscles, test cerebral function, test cranial nerve function, test deep tendon and superficial reflexes, test balance and coordination, test sensory function, test motor function, and observe for soft signs of neurologic problems

ch. 16 inspect the external eye structures and correctly use the ophthalmoscope to inspect internal eye structures

note width and position of external and internal eye structures, assess ability of eyelids to close, note position of eyelids in comparison to eyeballs (color, turnings, swelling, lesions, and discharge), observe eyeball position and alignment within socket, inspect the bulbar conjunctiva and sclera (clarity, color, and texture), inspect palpebral conjunctiva, lacrimal apparatus, cornea, lens, iris, and pupil, test reaction to light and accommodation of pupils, and inspect optic disc, retinal blood vessels, retinal background, fovea, and anterior chamber of the eye

ch. 1 discuss how nursing assessment skills are needed for every situation the nurse encounters

nurses constantly observe situations and collect information to make nursing judgments as they need to protect, promote, and optimize health and abilities, prevent illness and injury, and alleviate suffering through diagnosis and treatment

ch. 1 explain how the nurse's role in assessment has changed over the past century

nurses used the senses of sight, touch, and hearing to assess clients and now, communication and physical assessment techniques are used independently to arrive at professional clinical judgments concerning the client's health

ch. 22 perform a physical assessment of the peripheral vascular system using the correct techniques

observe arm size, venous pattern, edema, coloration of hands and arms, palpate the client's fingers, hands, and arms, temperature, radial pulse, brachial pulse, epitrochlear lymph nodes, ask client to lie supine, observe skin color of both legs, inspect distribution of hair, lesions or ulcers, edema, palpate edema, temperature, superficial inguinal lymph nodes, femoral pulse, auscultate femoral pulse, palpate popliteal pulse, dorsalis pedis pulse, posterior tibial pulse, and inspect varicosities and thrombophlebitis

ch. 13 perform a nutritional assessment including height, body build, and other anthropometric measurements using the correct techniques

observe client's general status and appearance, body build, muscle mass, fat distribution, measure height, weight, determine ideal body weight and percentage of IBW, body mass index, measure waist circumference, waist-to-hip ratio, mid-arm circumference, triceps skin-fold thickness, calculate mid-arm muscle circumference, measure intake and output, weigh clients at risk for hydration changes daily, take blood pressure with the client sitting down, lying down, or standing up, check skin turgor, pitting edema, observe moisture, assess venous filling, observe neck veins, inspect tongue condition and furrows, observe eye position and color, and auscultate lung sounds

ch. 21 perform a physical assessment of the heart and neck vessels using the correct techniques of inspection, auscultation, palpation, and percussion

observe jugular venous pulse, auscultate carotid arteries, palpate carotid arteries, inspect pulsations on anterior chest over heart, palpate apical impulse, auscultate heart rate and rhythm, identify S1 and S2, extra heart sounds, murmurs, and auscultate with client assuming other positions

ch. 24 perform a physical assessment of the musculoskeletal system using the correct techniques

observe posture and gait, inspect and palpate the TMJ, test ROM of the TMJ, inspect the sternoclavicular joint, observe the cervical, thoracic, and lumbar curves, palpate the spinous processes and the paravertebral muscles, test ROM of the cervical spine, test lateral bending, evaluate rotation, test ROM of the lumbar spine, test for back and leg pain, measure leg length, inspect and palpate shoulders and arms, test ROM of shoulders and arms, inspect for size, shape of deformities, redness, or swelling of elbows, test ROM of the elbows, perform the squeeze test on the hands, test ROM of the wrists, test for carpal tunnel syndrome, perform Phalen test, perform test for Tinel sign, observe for flick signal, test for thumb weakness, test ROM of the hands, test ROM of the hips, perform the bulge test if knees are swollen, perform the ballottement test, test ROM of the knees, test for pain and injury, inspect position, alignment, shape, and skin of client sitting, standing, and walking, palpate ankles and feet for tenderness, heat, swelling, or nodules, perform the squeeze test on the feet, and test ROM of the ankles

ch. 23 perform a physical assessment of the abdomen using the correct techniques

observe the coloration of the skin, note vascularity and striae, inspect for scars, assess for lesions and rashes, inspect umbilicus, observe umbilical location, assess contour of umbilicus, inspect abdominal contour, assess abdominal symmetry, inspect abdominal movement when breathing, observe aortic pulsations, observe for peristaltic waves, auscultate for bowel sounds and vascular sounds, listen for venous hum, percuss for tone, perform blunt percussion on the liver and kidneys, palpate lightly and deeply all quadrants to delineate abdominal organs and detect subtle masses, palpate the liver and urinary bladder, test for shifting dullness, perform the fluid wave test, assess for rebound tenderness, test for referred rebound tenderness, assess for obturator sign, perform hypersensitivity test, and test for cholecystitis

ch. 2 describe questions to ask to assess the client's lifestyle and health practices

questions of a typical day, nutrition and weight management, dietary intake, activities on a typical day, exercise habits and patterns, sleep and rest habits, use of medications, self-concept, self-care responsibilities, social activities, relationships, values, spirituality, education, type of work, finances, stressors in life, residency, and neighborhood

ch. 2 discuss the ways that ethnicity can affect communication patterns

reluctance to reveal personal information, willingness to express emotional distress, variation in ability to listen, meaning conveyed by language, meaning of nonverbal communication, disease and illness perception, past/present/future time orientation, and family's role in the decision-making process

ch. 6 describe risk factors for mental disorders and substance abuse across various cultures

risk factors for mental disorders and substance abuse include a history of early aggressive behavior, lack of parental supervision, history of substance abuse, drug availability, poverty, lack of self-control, academic competence, antidrug use policies at school, and strong neighborhood attachment

ch. 19 describe the teaching opportunities to reduce risks and promote health for the thorax and lungs

teach clients to avoid smoking cigarettes or join a tobacco cessation program, follow all preventative measures if exposed to occupational respiratory irritants, and tell them to teach their family about the disease, treatments, breathing techniques , proper positioning, and energy conserving methods

ch. 25 perform a physical assessment of the neurologic system using the correct techniques

test CN I (olfactory), test CN II (optic), assess CN III (oculomotor), CN IV (trochlear), VI (abducens), assess CN V (trigeminal), test CN VII (facial), test CN VIII (vestibulocochlear), test CN IX (glossopharyngeal) and X (vagus), test CN XI (spinal accessory), test CN XII (hypoglossal), assess condition and movement of muscles, assess strength and tone of all muscle groups, note any unusual involuntary movements, evaluate gait and balance, perform the Romberg test, assess coordination, assess rapid alternating movements, assess light touch, pain, and temperature sensations, test vibratory sensation, test sensitivity to position, assess tactile discrimination, test point localization, test graphesthesia, test extinction, test deep tendon reflexes, test biceps reflex, assess brachioradialis reflex, test triceps reflex, assess patellar reflex, test Achilles reflex, test ankle clonus, test superficial reflexes, assess plantar reflex, test abdominal reflex, test cremasteric reflex in males, assess client's neck mobility, test for Brudzinski sign, and test for Kernig sign

ch. 23 describe the structure and the function of the abdomen

the abdomen protects internal organs and allows normal compression during functional activities, composed of the transverse abdominis, internal abdominal obliques, external abdominal obliques, rectus abdominis, right upper quadrant (RUQ), left upper quadrant (LUQ), right lower quadrant (RLQ), left lower quadrant (LLQ), right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right iliac (inguinal), hypogastric, and left iliac (inguinal) regions

ch. 4 discuss the purposes of the client electronic health record (EHR)

the electronic health record refers to the more comprehensive health status of the client and not only the medical status, EHRs focus on the total health (emotional, physical, social, and spiritual) of the client and are designed to reach out beyond the health organization

ch. 20 describe the findings frequently seen with assessing the older client's breasts and axillary lymph nodes

with older clients, assess a decrease in the size and firmness of breasts, pendulous and saggy breasts, smaller and flatter nipples, and granular tissue

ch. 22 describe the findings frequently seen with assessing the older client's peripheral vascular system

with older clients, assess abnormal sensations, coldness, color change, numbness, lost lymphatic tissue, smaller and fewer lymph nodes, hair loss, and varicosities

ch. 25 describe the findings frequently seen with assessing the older client's neurologic system

with older clients, assess decreased taste and scent sensation, decreased ability to hear, decrease in ability to see, intentional tremors, reduced muscle mass, degeneration of muscle fibers, hand or head tremors, dyskinesia, slow and uncertain gait, decreased flexibility and strength, decreased reaction time, reduced light touch and pain sensations, absent vibration sense, reduced position of big toe, slowed deep tendon reflexes, absent Achilles reflex, and difficult flexion of toes

ch. 23 describe the findings frequently seen with assessing the older client's abdomen

with older clients, assess diminished sensitivity to pain, decline in appetite, diarrhea, urinary tract infections, dilated superficial capillaries, and width of aorta

ch. 19 describe the findings frequently seen when assessing the older client's thorax and lungs

with older clients, assess dyspnea, chest pain, decreased ability to cough, kyphosis (increased curve of thoracic spine), decreased thoracic expansion, difficulty deep breathing, and tenderness or pain at the costochondral junction

ch. 2 describe ways to adapt the interview for the older client

with older clients, assess hearing acuity, speak slowly and clearly, face the client, speak on their good side, establish trust, maintain privacy, treat them as equals, use straight forward language, and show respect

ch. 8 describe findings often seen when assessing an older client's general health status and vital signs

with older clients, assess osteoporotic thinning, collapse of vertebrae, lower normal body temperature, rigid and bent arteries, higher respiratory rate, and higher blood pressure

ch. 21 describe the findings frequently seen when assessing the older client's heart and neck vessels

with older clients, atherosclerosis can cause obstruction and compression and the apical impulse is difficult to palpate

ch. 24 describe the findings frequently seen with assessing the older client's musculoskeletal system

with older clients, bones lose density, osteomalacia or osteoporosis, joint stiffening, arthritis, bone resorption increases, calcium absorption decreases, production of osteoblasts decreases, decreased flexibility, slower movements, decreased muscle strength, impaired sense of positioning, kyphosis, can bend forward, cannot touch toes, and bow-legged appearance

ch. 15 describe subjective and objective findings frequently seen when assessing the older client's head and neck

with older clients, facial wrinkles are prominent, subcutaneous fat decreases with age, strength of temporal artery decreases, cervical curvature may increase (kyphosis), decreased flexion, extension, lateral bending, and rotation of neck, arthritis is common, and thyroid feels more nodular or irregular

ch. 18 describe findings frequently seen when assessing the older client's mouth, throat, nose, and sinuses

with older clients, gums recede, become ischemic, undergo fibrotic changes, tooth surfaces may be worn, susceptible to periodontal disease and tooth loss, ability to smell and taste decreases, difficulty caring properly for teeth or dentures, poor vision, impaired dexterity, teeth may appear longer, oral mucosa is often drier and more fragile, epithelial lining of the salivary glands degenerates, and may have varicose veins on the tongue's ventral surface

ch. 13 describe the findings frequently seen when assessing the older client's nutritional status

with older clients, muscle tone and mass decrease with aging, fat is redistributed, height begins to wane, intervertebral discs become thinner, consumption of food is decreased, and less activity is performed

ch. 14 recognize how assessment findings may vary in the older adult

with older clients, skin becomes pale due to decreased melanin production and dermal vascularity, skin lesions can be associated with aging, skin may feel drier, decrease in elasticity and collagen fibers, sagging or wrinkled skin, hair feels coarser and drier, thinner hair, decrease in hair follicles, and nails may appear thicker, yellow, and brittle

ch. 27 describe the findings frequently seen with assessing the older client's female genitalia, anus, and rectum

with older clients, susceptibility to vaginal infection is increased, painful sexual intercourse, estrogen production is decreased, atrophy of vaginal mucosa, urinary incontinence, gray and thinning pubic hair, and pale cervix

ch. 26 describe the findings frequently seen with assessing the older male client's genitalia, anus, rectum, and prostate

with older male clients, the scrotum enlarges, erectile dysfunction increases, gray and sparse pubic hair, smaller penis, lower hanging scrotum, drooping scrotal sac, fewer rugae in scrotal sac, and smaller and softer testes