Health Assessment - Midterm Exam
A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit (per minute)?
16
Location - Apex of Lung
3 to 4cm above the inner third of the clavicles
A function of the venous system includes: A) Holding more blood when blood volume increases B) Conserving fluid and plasma proteins that leak out of the capillaries C) Forming a major part of the immune system that defends the body against disease D) Absorbing lipids from the intestinal tract
A
A known risk factors for venous ulcer development is: A) Obesity B) Male gender C) History of hypertension D) Daily aspirin therapy
A
A major characteristic of dementia is: A) Impairment of short- and long-term memory B) Hallucinations C) Sudden onset of symptoms D) Substance-induced
A
A nurse is instructing an assistive personal (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A) "Do not measure the client's temperature rectally" B) "Count the client's radial pulse for 30 seconds and multiply it by 2" C) " Do not let the client know you are counting their respirations" D) "Let the client rest for 5 minute before you measure their blood pressure"
A
An older adult's advanced activities of daily living would include: A) Recreational activities B) Meal preparation C) Balancing the checkbook D) Self-grooming activities
A
An older person needs to be assessed before going home as to whether he or she is able to go outside alone safely. Which test is best for this assessment? A) Time Up and Go Test B) Performance of Activities of Daily Living Test C) Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire D) Lawton IADL instrument
A
Assessment of the social domain includes: A) Family relationships B) Ability to cook meals C) Ability to balance the checkbook and pay bills D) Hazards found in the home
A
Atrophic skin changes that occur with peripheral arterial insufficiency include: A) Thin, shiny skin with loss of hair B) Brown, discoloration C) Thick, leathery skin D) Slow-healing blisters on the skin
A
During a routine visit, M.B., age 78, asks about small, round, flat, brown macules on the hands. What is your best response after assessing the areas? A) These are the result of sun exposure and do not require treatment B) These are related to exposure to the sun. They may become cancerous C) These are the skin tags that occur with aging. No treatment is required D) I'm glad you broth this to my attention. I will arrange for a biopsy
A
During an initial home visit, the patient's temperature is noted to be 97.4 F. How would you interpret this? A) It cannot be evaluated without knowledge of the person's age. B) It is below normal. The person should be assessed for possible hypothermia C) It should be retaken by the rectal route, because this best reflects core body temperature D) It should be reevaluated at the next visit before a decision is made
A
During an interview, a patient denies having any anxiety. The patient frequently changes position in the chair, holds his arms folded tight against his chest, and has little eye contact with the interviewer. The interviewer should: A) Use confrontation to bring the discrepancy between verbal and nonverbal behavior to the patient's attention B) Proceed with the interview. Patients usually are truthful with a health care practitioner C) Make a mental note to discuss the behavior after physical examination is completed D) Proceed with the interview and examination as outlined on the agency assessment form. The patient's behavior is appropriate for the circumstances
A
During the examination of the lower extremities, you are unable to palpate the popliteal pulse. You should: A) Proceed with the examination. It is often impossible to palpate this pulse B) Refer the patient to a vascular surgeon for further evaluation C) Schedule the patient for a venogram D) Schedule the patient for an arteriogram
A
Pulse pressure is described as: A) The difference between systolic and diastolic pressure. B) A reflection of the viscosity of the blood C) Another way to express the systolic pressure D) A measure of vasoconstriction
A
Select the findings that most accurately describes appearance of a patient. A) Tense posture and restless activity. Clothing clean but not appropriate for season B) Oriented X 3. Affect appropriate for circumstances C) Alert and responds to verbal stimuli. Tearful when diagnosis discussed D) Laughing inappropriately, oriented x 3
A
The bell of the stethoscope is used: A) For soft, low-pitched sounds B) For high-pitched sounds C) To hold firmly against the skin D) To magnify sound
A
The practitioner, entering the examining room to meet a patient for the first time, states: Hello, I'm M.M,. and I'm here to gather some information from you and to perform your examination. This will take about 30 minutes. D.D. is a student working with me. If it's all right with you, she will remain during the examination." Which of the following must be added to cover all aspects of the interview contract. a. A statement regarding confidentiality, patient costs, and the expectations of each person. b. the purpose of the interview and the role of the interviewer. c. Time and place of the interview and a confidentiality statement. d. An explicit purpose of the interview and a description of the physical examination, including diagnostic studies.
A
To assess for early jaundice, you will assess: A. sclera and hard palate B. nail beds C. lips D. all visible skin surfaces
A
What does active listening NOT include? A) Taking detailed notes during the interview B) Watching for clues in body language C) Repeating statements back to the person to make sure you have understood D) Asking open-ended questions to explore the person's perspective
A
What is the best description of "review of systems" as part of the health history? A) The evaluation of the past and present health state of each body system B) A documentation of the problem as described by the patient C) The recording of the objective findings of the practitioner D) A statement that describes the overall health state of the patient
A
When auscultating the heart, your first step is to: A) Identify S1 and S2 B) Listen for S3 and S4 C) Listen for murmurs D) Identify all four sounds on the first round
A
When reading a medical record, you see the following notation: Patient states, "I have had a cold for about a week, and now I am having difficulty breathing." This is an example of: A) A past health history B) A review of systems C) A functional assessment D) A reason for seeking care
A
When you perform a functional assessment of an older patient, which is most appropriate? A) Observe the patient's ability to perform the tasks B) Ask the patient's partner how he or she does when performing tasks C) Review the medical record for information on the patient's abilities D) Ask the patient's physician for information on the patient's abilities
A
Which best describes evidence-based nursing practice? A) Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances B) Appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient C) Completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices D) Finding value-based resources to justify nursing actions when working with patients of diverse cultural backgrounds
A
Which description would differentiate a split S2 form S3? A) S3 is lower pitched and is heard at the apex B) S2 is heard at the left lower sternal border C) The timing of S2 varies with respirations D) S3 is heard at the base; the timing varies with respirations
A
Which is an example of an informal social support network for the aging adult? A) A neighbor who drops by with newspapers and magazines on a regular basis B) An area church that offers a weekly activity and luncheon for seniors in the neighborhood C) A home health care agency that provides weekly blood pressure screenings at the church luncheon D) A senior citizen chess club whose members hold classes at the local Boys' Club
A
Why is it important to match the appropriate size of blood pressure cuff to the person's arm and shape and not to the person's age? A) Using a cuff that is too narrow will give a false reading that is too high B) Using a cuff that is too wide will give a false reading that is too low C) Using a cuff that is too narrow will give a false reading that is too low D) Using a cuff that is too wide will give a false reading that is too high
A
You are assessing capillary refill. The room is warm. Which finding would be considered normal? A) <1 second B) >2 seconds C) 2 to 3 seconds D) Time is not significant as long as color returns
A
You are leading a discussion of the planned activities for the day at an adult living center and state, "We will be having snacks at 9:30 and lunch will be at noon. One of the participants responds in a very monotone manner, "Snacks at 9:30, lunch at noon, snacks at 9:30, lunch at noon." This patient is exhibiting signs of: A) Echolalia B) Confabulation C) Flight of ideas D) Neologisms
A
You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed? A) Planning B) Assessment C) Implementation D) Diagnosis
A
You auscultate a patient to rule out a pericardial friction rub. Which assessment technique is most appropriate? A) Listen with the diaphragm, patient sitting up and leasing forward, breath held in expiration B) Listen using the bell with the patient leaning forward C) Listen at the base during normal respiration D) Listen with the diaphragm, patient turned to the left side
A
You have reason to question the reliability of the information being provided by a patient. One way to verify the reliability within the context of the interview is to: A) Rephrase the same question later in the interview B) Review the patient's previous medical records C) Call the person identified as the emergency contact to verify the data provided D) Provide the patient with a printed history to complete and then compare the data provided
A
_________________ is exhibiting an accurate understanding of the other person's feelings within a communication context. A) Empathy B) Liking others C) Facilitation D) A nonverbal listening technique
A
A nurse in a provider's office is preparing to ausculate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? A) Tympany B) High-pitched clicks C) Borborygmi D) Friction rubs E) Bruits
A B
A nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the follow parameters should the nurse include as part of the general survey? A) Posture B) Skin lesion C) Speech D) Allergies E) Immunization status
A B C
A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? A) Place the client in semi-Fowler's position B) Have the client rest an arm across the abdomen C) Observe one full respiration cycle before counting the rate D) Count the rate for 30 sec if it is irregular E) Count and report any sighs the client demonstrates
A B C
A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 (101), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? A) Obtain culture specimens before initiating antimicrobials. B) Restrict the client's oral fluid intake. C) Encourage the client to rest and limit activity. D) Allow the client to shiver to dispel excess heat. E) Assist the client with oral hygiene frequently.
A C E
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? A) Capillary refill less than 3 sec B) 1+ pitting edema in both feet C) Pale nail beds in both hands D) Thick skin on the soles of the feet E) Numerous macules on the face darker than the surrounding skin color
A D E
Pulse oximetry measures: A) Arterial oxygen saturation of hemoglobin B) Venous oxygen saturation of hemoglobin C) Combined saturation of arterial and venous blood D) Carboxyhemoglobin levels
A) Arterial oxygen saturation of hemoglobin
A patient has barrel-shaped chest, characterized by: A) Equal anteroposterior transverse diameter and ribs being horizontal B) Anteroposterior transverse diameter of 1:2 and an elliptic shape C) Anteroposterior transverse diameter of 2:1 and ribs being elevated D) Anteroposterior transverse diameter of 3:7 and ribs sloping back
A) Equal anteroposterior transverse diameter and ribs being horizontal
Which of the following assessments best confirms symmetric chest expansion? A) Placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pinch a small fold of skin between the thumbs B) Inspection of the shape and configuration of the chest wall C) Placing the palmar surface of the fingers of one hand against the chest and having the person repeat the words "ninety-nine" D) Percussion of the posterior chest
A) Placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pinch a small fold of skin between the thumbs
The manubriosternal angle is... A) The articulation of the manubrium and the body of the sternum B) A hollow, U-shaped depression just above the sternum C) Also known as the breastbone D) A term synonymous with costochondral junction
A) The articulation of the manubrium and the body of the sternum
what are the main headings of a mental status assessment?
A-B-C-T appearance behavior cognition thought process
what is the skin self-examination technique?
ABCDEF - asymmetry, border irregularity, color variations, diameter greater than 6mm, elevation or evolution, funny looking
Pallor
Absence of red-pink tones from the oxygenated hemoglobin in blood
Irritability
Annoyed, easily provoked
Anxiety
Apprehensive from the anticipation of a danger whose source is unknown
A nurse is collecting data for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skills of the physical examination process should the nurse perform next? A) Olfaction B) Auscultation C) Palpation D) Percussion
B
A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A) Request a prescription for an antihypertensive medication B) Ask the client if they are having pain C) Request a prescription for anti-anxiety medication D) Return in 30 min to recheck the client's blood pressure
B
A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A) Pallor B) Cyanosis C) Jaudice D) Erythema
B
A patient is in the emergency department with nausea and vomiting. Which would you include in the database? A) A complete health history and full physical examination B) A diet and GI history C) Previously identified problems D) Start collection of data in conjunction with lifesaving measures
B
A patient's pulse with an amplitude of 3+ indicates: A) Irregular, with 3 premature beats B) Increased, full C) Normal D) Weak
B
After assessing the patient's pulse, the practitioner determines it to be 'normal'. This would be recorded as: A) 3+ B) 2+ C) 1+ D) 0
B
An appropriate tool to assess an individual's instrumental activities of daily living is a tool by: A) Katz B) Lawton C) Tinetti D) Norbeck
B
An older adult has had surgery for a fractured hip and has a history of dementia. You should keep in mind that older adults with mild cognitive impairment: A) Experience less pain B) Can provide a self-report of pain C) Cannot be relied on to self-report pain D) Will not express pain sensations
B
Arteriosclerosis is caused by: A) Deposition of fatty plaques on the intima of the arteries B) Loss of elasticity of the walls of blood vessels C) Loss of lymphatic tissue that occurs in the aging process D) Progressive enlargement of the intramuscular calf veins
B
Assessing a patient's skin turgor is done to assess which clinical finding? A) Edema B) Dehydration C) Vitiligo D) Scleroderma
B
Atrial systole occurs: A) During ventricular systole B) During ventricular diastole C) Concurrently with ventricular systole D) Independently of ventricular function
B
During an initial interview, the examiner says, "Mrs. J., tell me what you do when your headaches occur?" This is an example of which type of information? A) The patient's perception of the problems B) aggravating or relieving factors C) The frequency of the problems D) The severity of the problem
B
During an interview with a patient diagnosed with a seizure disorder, the patient states, "I plan to be an airline pilot." If the patient continues to have this as a career goal after teaching regarding seizure disorders has been provided, you might question the patient's: A) Thought processes B) Judgement C) Attention span D) Recent memory
B
For a health assessment, which assessment technique will you use first? A) Palpation B) Inspection C) Percussion D) Ausculation
B
Herpes zoster infection (shingles) is characterized by: A) A bacterial cause B) Lesion on only one side of body; does not cross midline C) Absence of pain or edema D) Pustular, umbilicated lesion
B
Knowledge of the use of personal space is helpful for health care provider. Personal distance is generally considered to be: A) 1 to 1 1/2 feet B) 1 1/2 to 4 feet C) 4 to 13 feet D) 12 or more feet
B
One way to assess cognitive function and to screen dementia is with: A) The Proverb Interpretation Test B) The Mini-Cog C) The Denver II D) The Older Adult Behavioral Checklist
B
Raynaud phenomenon occurs: A) When the patient's extremities are exposed to heat and compression B) In hands and feet as a result of exposure to cold, vibration, and stress C) After removal of lymph nodes or damage to lymph nodes and channels D) As a result of leg cramps due to excessive walking or climbing stairs
B
Select the best description of an accurate assessment of a patient's pulse. A) Count for 15 sec if the pulse is regular B) Begin counting with zero; count for 30 sec C) Count for 30 sec and multiply by 2 for all cases D) Count or 1 full minute; begin counting with zero
B
Select the best description of the tricuspid valve: A) Left semilunar valve B) Right atrioventricular valve C) Left atrioventricular valve D) Right semilunar valve
B
The Lawton IADL instrument is described by which of the following? A) The nurse uses direct observation to implement this tool B) It is designed as a self-report measure of performance rather than ability C) It is not useful in the acute hospital setting D) It is best used for those residing in an institutional setting
B
The best description of the pitch of a sound wave obtained by percussion is: A) The intensity of the sound B) The number of vibrations per second C) The length of time the note lingers D) The overtones of the note
B
The examiner is palpating the apical impulse. Which is a normal-sized impulse? A) Less than 1 cm B) Approximately 1 X 2 cm C) 3 cm D) Varies depending on the size of the person
B
The expert nurse differs from the novice nurse by acting without consciously thinking about the actions. This is referred to as: D) Deductive reasoning B) Intuition C) The nursing process D) Focused assessment
B
The function of the pulmonic valve is to: A) Divid the left atrium and left ventricle B) Guard the opening between the right atrium and right ventricle C) Protect the orifice between the right ventricle and the pulmonary artery D) Guard the entrance to the aorta from the left ventricle
B
The nurse auscultates the pulmonic valve area in which region? A) Second right interspace B) Second left interspace Left lower sternal border D) Fifth interspace, left midclavicular line
B
The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults? A) The pulse is more difficult to palpate because of the stiffness of the blood vessels B) An increased respiratory rate and a shallower inspiratory phase are possible findings C) A decreased pulse pressure occurs from changes in systolic and diastolic blood pressures. D) Changes in the body's temperature regulatory mechanism leave the older adult more likely to develop fever
B
What statement is an example of a patient with dysarthria? A) When asked a question, the patient responds fluently but uses words incorrectly or makes up words so that speech may be incomprehensible. B) The word choice and grammar are appropriate, but the sounds are distorted so speech is unintelligible C) The pitch and volume of words are difficult and the voice may be hoarse, but language is intact D) Comprehension is intact but there is difficulty in expressing thoughts, with nouns and verbs being the dominate word choice
B
When assessing the carotid artery, the nurse should palpate: A) Bilaterally at the same time while standing behind the patient B) Medial to the sternomastoid muscle, one side at a time C) For a bruit while asking the patient to hold his or her breath briefly D) For unilateral distention while turning the patient's head to one side
B
When completing a spiritual assessment, you should: A) Use yes and no questions as the foundation for future dialogue B) Use open-ended questions to help the patient understand potential coping mechanisms C) Try to complete this assessment as soon as possible after meeting the patient D) Wait until a member of the clergy can be involved in the assessment
B
When interviewing a patient who does not speak English, the examiner should: A) Take advantage of family members who are readily available and willing to assist B) Use a qualified medical interpreter who is culturally literate C) Seek as much information as possible and then continue with the physical examination D) Wait until a qualified medical interpreter is available before starting the interview
B
When using the various instruments to assess an older person's activities of daily living (ADLs), remember that a disadvantage of these instruments includes: A. the reliability of the tools B. self or proxy report of functional activities C. lack of confidentiality during the assessment D. insufficient detail about the deficiencies identified
B
Which demonstrates a good understanding of the interview process? A) The nurse stops the patient each time something is said that is not understood. B) The nurse spends more time listening to the patient than talking C) The nurse is consistently thinking of his or her next response so the patient will know he or she is understood D) The nurse uses "why" questions to seek clarification of unusual symptoms or behavior
B
With older adults, how should the examiner proceed with the interview? A) Proceed in a more organized and concise manner B) Consider the fatigue of the older person and break the interview into shorter segments C) Asks a family member to complete some of the records while moving ahead with the interview D) Raise you voice if the patient does not appear to hear you
B
You assess a patient for arterial deficit in the lower extremities. After raising the legs 12 inches off the table and then having the person sit up and dangle the leg, the color should return in: A) 5 seconds or less B) 10 seconds or less C) 15 seconds D) 30 seconds
B
You conduct an admission interview. Because you are expecting a phone call, you stand near the door. Which would be a more appropriate approach? A) Arrange to have someone page you so you can sit on the side of the bed B) Have someone else answer the phone so you can give the patient your full attention C) Use this approach given the circumstances D) Arrange for a time free of interruptions after the initial physical examination is complete
B
You will hear a split S2 most clearly in which area? a. apical b. pulmonic c. tricuspid d. aortic
B
A nurse is assessing an older adult client who has significant tenting of the skin over the forearm. Which of the following factors should the nurse consider as a cause for this finding? A) Thin, parchment-like skin B) Loss of adipose tissue C) Dehydration D) Diminished skin elasticity E) Excessive wrinkling
B C D
A nurse is preparing to perform a comprehensive physical examination of an older adult. Which of the following interventions should the nurse use in consideration of the client's age? A) Expect the session to be shorter than for a younger client B) Plan to allow plenty of time for position changes C) Make sure the client has any essential sensory aids in place D) Tell the client to take their time answering question E) Invite the client to use the bathroom before beginning the examination
B C D E
A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should test which of the following? A) Range of motion B) Skin color C) Edema D) Skin lesions E) Skin temperature
B C E
A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurses use with this client? A) Address the client with the appropriate title and their last name B) Use a mix of open- and closed-ended questions C) Reduce environmental noise D) Have the client complete a printed history from E) Perform the general survey before the examination
B C E
During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? A) Ventricular gallop B) Closure of the mitral valve C) Closure of the pulmonic valve D) Apical heart rate E) Murmur
B D
You are auscultating breath sounds on a patient. Which of the following best describes how to proceed? A) Hold the bell of the stethoscope against the chest wall; listen to the entire right field and then the entire left field B) Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons C) Listen from the apices to the bases of each lung field using the bell of the stethoscope D) Select the bell or diaphragm depending on the quality of sounds heard; listen for one respiration in each location, moving from side to side
B) Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons
Select the best description of the bronchovesicular breath sounds. A) High-pitched, of longer duration on inspiration than expiration B) Moderate-pitched, inspiration equal to expiration C) Low-pitched, inspiration greater than expiration D) Rustling sound, like the wind in the trees
B) Moderate-pitched, inspiration equal to expiration
Select the correct description of the left lung. A) Narrower than the right lung with three lobes B) Narrower than the right lung with two lobes C) Wider than the right lung with two lobes D) Shorter than the right lung with three lobes
B) Narrower than the right lung with two lobes
You assess a patient who reports a cough. The characteristic timing of the cough of chronic bronchitis is described as: A) Continuous throughout the day. B) Productive cough for at least 3 months of the year for 2 consecutive years C) Occurring in the afternoon or evening because of exposure to irritants at work D) Occurring in the early morning
B) Productive cough for at least 3 months of the year for 2 consecutive years
Cyanosis
Bluish mottled color that signifies decreased perfusion
A configuration of individual lesions arranged in circles or arcs, as occurs with ringworm, is described as a: A) Linear lesion B) Clustered lesions C) Annular lesion D) Gyrate lesion
C
A genogram is used for which reasons? A) Past history B) Past health history, specifically hospitalizations C) Family history D) The 8 characteristics of presenting symptoms
C
A murmur is heard after S1 and before S2. This murmur would be classified as: A) Diastolic (possibly benign) B) Diastolic (aways pathologic) C) Systolic (possibly benign) D) Systolic (always pathologic)
C
A nurse in a provider's office is performing a physical examination of an adult client. What part of the hands should the nurse use during palpation for optimal assessment of skin temperature? A) Palmar surface B) Fingertips C) Dorsal surface D) Base of the fingers
C
A patient asks the nurse, "May I ask you a question?" This is an example of: A) An open-ended question B) A reflective question C) A closed question D) A double-barreled question
C
A patient has recently received health insurance and would like to know how often he should visit the provider. How do you respond? A) It would be most efficient if you visit on an annual basis B) There is no recommendation for the frequency of health care visits C) Your visits may vary, depending on your level of wellness D) Your visits will be based on your preference
C
A patient is being seen in the clinic for complains of "fainting episodes that started last week". How should you proceed with the examination? A) Take the blood pressure in both arms and thighs B) Ask the person to walk a few paces and then take the blood pressure C) Record the blood pressure in the lying, sitting, and standing position D) Record the blood pressure in the lying and sitting positions and average these number to obtain a mean blood pressure
C
A patient says she is very nervous and nauseated, and she feels as if she will vomit. This data would be what type of data? A) Objective B) Reflective C) Subjective D) Introspective
C
A risk factor for melanoma is: A) Brown eyes B) Darkly pigmented skin C) Skin that freckles or burns before tanning D) Use of sunscreen products
C
An appropriate use of the Caregiver Strain Index would be which situation? A) A daughter who is taking her older father home to live with her B) An older patient who lives alone C) A wife who has cared for her husband for the past 4 years at home D) A son whose parents live in an assisted living facility
C
An area of thin shiny skin with decreased visibility of normal skin markings is most likely: A) Lichenification B) Plaque C) Atrophy D) Keloid
C
During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A) Fat B) Fluid C) Flatus D) Hernias
C
During the evaluation phase of the nursing process, which action would be included? A) Validating the nursing diagnosis B) Establishing priorities related to patient care C) Including the patient and family members D) Establishing a timeline for planned outcomes
C
Inspection of a person's right hand reveals a red, swollen area. To further assess for infection, you would palpate the: a) cervical node b) axillary node c) epitrochlear node d) inguinal node
C
Intermittent claudication includes: A) Muscular pain relieved by exercise B) Neurologic pain relieved by exercise C) Muscular pain brought on by exercise D) Neurologic pain brought on by exercise
C
Mr. B tells you, "Everyone here ignores me." You respond, "Ignores you?" This technique is best described as: A) Clarification B) Selective listening C) Reflecting D) Validation
C
Ms T has come for a prenatal visit. She complains of dependent edema, varicosities in the legs, and hemorrhoids. The best response is: A) If these symptoms persist, we will perform an amniocentesis B) If these symptoms persist, we will discuss having you hospitalized C) The symptoms are caused by the pressure of the growing uterus on the veins. They are usual conditions of pregnancy D) At this time, the symptoms are a minor inconvenience. You should learn to accept them.
C
On a patient's second day in an acute care hospital, the patient complains about the "bugs" on the bed. The bed is clean. This would be an example of altered: A) Thought process B) Orientation C) Perception D) Higher intellectual function
C
The A in the ABCDER rule for skin cancer stands for: A) Accuracy B) Appearance C) Asymmetry D) Attenuated
C
The concept of health and healing has evolved in recent years. Which is the best description of health? A) Health is the absence of disease B) Health is a dynamic process towards optimal functioning C) Health depends on an interaction of mind, body, and spirit within the environment D) Health is the prevention of disease
C
The ophthalmoscope has 5 apertures. Which aperture is used to assess the eyes of a patient with undilated pupils? A) Grid B) Slit C) Small D) Large
C
The precordium is: A) A synonym for the mediastinum B) The area on the chest where the apical impulse is felt C) The area on the anterior chest overlying the heart and great vessels D) A synonym for the area where the superior and inferior venae cavae return unoxygenated venous blood to the right side of the heart
C
The statement "Reason for seeking care" has replaced the "chief complaint." This change is significant beacause: A) The "chief complaint" is really a diagnostic statement B) The newer term allows another individual to supply the necessary information C) The newer term incorporates wellness needs D) The "reason for seeking care" can incorporate the history of the present illness
C
The stethoscope bell should be pressed lightly against the skin so that: A) Chest hair doesn't simulate crackles B) High-pitched sounds can be heard better C) The bell does not act as a diaphragm D) The bell does not interfere with amplification of heart sounds
C
What can be determined when the nurse clusters data as part of the critical-thinking process? A) This step identifies problems that may be urgency and require immediate action B) This step involves making assumptions in the data C) The nurse recognizes relevant information among the data D) Risk factors can be determined so the nurse knows how to offer health teaching.
C
When performing indirect percussion, the stationary finger is struck: A) At the ulnar surface B) At the middle joint C) At the distal interphalangeal joint D) Where it is in contact with the skin
C
Which is an appropriate recording of a patient's reason for seeking health care? A) Angina pectoris, duration 2 hours B) Substernal pain radiating to left axilla, 1 hour duration C) "Grabbing" chest pain for 2 hour D) Pleurisy, 2 days' duration
C
Which of the following organs aid the lymphatic system? A) Liver, lymph nodes, and stomach B) Pancreas, small intestine, and thymus C) Spleen, tonsils, and thymus D) Pancreas, spleen, and tonsils
C
Which statement is true regarding an individual's functional status? A) Functional status refers to one's ability to care for another person B) An older adult's functional status is usually static over time C) An older adult's functional status may vary from independence to disability D) Dementia is an example of functional status
C
Which would be considered a risk diagnosis? A) Identifying existing levels of wellness B) Evaluating previous problems and goals C) Identifying potential problems the individual may develop D) Focusing on strengths and reflecting an individual's transition to higher levels of wellness
C
Which would be included in a holistic model of assessment? A) Nursing goals for the patient B) Anticipated growth and development patterns C) A patient's perception of his or her health status D) The nurse's perception of disease related to the patient
C
You are performing a mental status examination. Which assessments would be most appropriate? A) Examining the patient's EEG B) Observing the patient as he or she takes an IQ test C) Observing the patient and inferring health or dysfunction D) Examining the patient's response to a specific set of questions
C
You are preparing the discharge plan for a patient with aphasia. What assessment should you include in the plan? A) Ask the patient to calculate serial 7s B) Ask the patient to name his or her grandchildren and their birthdays C) Ask the patient to demonstrate word comprehension by naming articles in the room or on the body as you point to them D) Ask the patient to interpret a proverb
C
You are reviewing assessment data of a 45-year-old male patient and note pain of 8 on a scale of 10, labored breathing, and pale skin color on the electronic health record. This documentation is an example of: A) Hypothetical reasoning B) Diagnostic reasoning C) Data cluster D) Signs and symptoms
C
You examine the nail beds of a patient. Which finding indicates a normal angle? A) 60 degrees B) 100 degrees C) 160 degrees D) 180 degrees
C
A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? A) Rhonchi B) Crackles C) Resonance D) Tactile fremitus E) Bronchovesicular sounds
C E
A pleural friction rub is best detected by: A) Observation B) Palpation C) Auscultation D) Percussion
C) Auscultation
On examining a patient's nails, you note that the angle of the nail base is >160 degrees and that the nail base feels spongy to palpation. These findings are consistent with: A) Acute respiratory distress syndrome B) Normal findings for the nails C) Congenital heart disease and COPD D) Atelectasis
C) Congenital heart disease and COPD
When examining for tactile fremitus, it is important to: A) Ask the patient to breathe quickly B) Ask the patient to cough C) Palpate the chest symmetrically D) Use the bell of the stethoscope
C) Palpate the chest symmetrically
Location - Posterior Apex of Lungs
C7
You are assessing a 75-year-old man. What is an expected finding? A) He will have no decrease in any of his abilities, including response time B) He will have difficulty on tests of remote memory because this typically decrease with age C) It may take him a little longer to respond but his general knowledge and abilities should not have declined D) He will have had a decrease in his response time due to language loss and a decrease in general knowledge
Cf
A 54-year-old woman with 5 children has varicose veins of the lower extremities. Her most characteristic sign is: A) Reduce arterial circulation B) Blanching, deathlike appearance of the extremities on elevation C) Loss of hair on feet and toes D) Dilated, tortuous superficial bluish vessels
D
Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are: A) memory, attention, thought content, and perceptions. B) language, orientation, attention, and abstract reasoning. C) appearance, behavior, cognition, and thought processes. D) mood, affect, consciousness, and orientation.
D
An older person is experiencing an acute change in cognition. You recognize that this disorder is: A) Alzheimer dementia B) Attention deficit disorder C) Depression D) Delirium
D
At the conclusion of the patient examination, the examiner should: A) Document findings after leaving the examination room B) Have findings confirmed by another practitioner C) Relate objective findings to the subjective findings for accuracy D) Summarize findings to the patient
D
Checking for skin temperature is best accomplished by using: A) The palmar surface of the hands B) The ventral surface of the hands C) The fingertips D) The dorsal surface of the hands
D
During the assessment, which part of the hand is best for detecting vibration? A) Fingertips B) Index finger and thumb in opposition C) Dorsum of the hand D) Ulnar surface of the hand
D
Flattening of the angle between the nail and its base is: A) Found in subacute bacterial endocarditis B) A description of spoon-shaped nails C) Related to calcium deficiency D) Described as clubbing
D
For what or with whom should touch be used during the interview? A) Only with individuals from a Western culture B) As a routine way of establishing contact with a person and communicating empathy C) Only with patients of the same gender D) Only if the interviewer knows the person well
D
Mean arterial pressure is: A) The arithmetic average of systolic and diastolic pressures B) The driving force of blood during systole C) Diastolic pressure plus one third of the pulse pressure D) Corresponding to phase III Korotkoff
D
Select the best description of an accurate assessment of a patients' respiration. A) Count for a full minute before taking the pulse B) Count for 15 sec and multiply by 4 C) Count after informing the patient where you are in the assessment process D) Count for 30 sec after pulse assessment
D
Select the best description of the secretion of the eccrine glands. A) Thick, milky B) Dilute saline solution C) Protective lipid substance D) Keratin
D
The examiner is has estimated the jugular venous pressure. Identify the finding that is abnormal. A) Patient elevated to 30 degrees, internal jugular vein pulsation at 1 cm above sternal angle B) Patient elevated to 30 degrees, internal jugular vein pulsation at 2 cm above sternal angle C) Patient elevated to 40 degrees, internal jugular vein pulsation at 1 cm above sternal angle D) Patient elevated to 45 degrees, internal jugular vein pulsation at 4cm above
D
The examiner suspects a patient has coarctation of the aorta. Which assessment finding supports this suspicion? A) The thigh pressure is higher than in the arm B) The thigh pressure is equal to that in the arm C) The thigh pressure is unrelated to the arm pressure. There is no constant relationship; findings are high individual D) The thigh pressure is lower than in the arm
D
The nurse uses health promotion activities with a new patient. What would this focus include? A) The nurse would try to change the patient's perceptions of disease B) The nurse would search for identification of biomedical model interventions C) The nurse would help to identify negative health acts of the patient D) The nurse would empower the patient to choose a healthier lifestyle
D
The second heart sound is the result of: A) Opening of the mitral and tricuspid valves B) Closing of the mitral and tricuspid valves C) Opening of the aortic and pulmonic valves D) Closing of the aortic and pulmonic valve
D
To assess a patient's abdomen by palpation, how should the nurse proceed? A) Avoid palpation of reported tender areas because this may cause the patient pain B) Quickly palpate a tender area to avoid any discomfort that the patient may experience C) Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched
D
To screen for deep vein thrombosis, you would: A. measure the circumference of the ankle B. check the temperature with the palm of the hand C. compress the dorsalis pedis pulse, looking for blood return D. measure the widest point with a tape measure
D
What is a priority assessment for aging adults? A) Phobias B) General intelligence C) Irrational thinking patterns D) Sensory perceptive abilities
D
When inspecting the ear canal of a patient, the examiner chooses which speculum for the otoscope? A) A short, broad one B) The narrowest for a child C) The longest for an adult D) The largest that will fit
D
Which finding is considered to be subjective? A) Temperature of 101.2 F B) Pulse rate of 96 beats/ min C) Measured weight loss of 20 pounds since the previous measurement D) Pain lasting 2 hours
D
Which is an example of objective data? A) Patient's history of allergies B) Patient's use of medications at home C) Last menstrual period 1 month ago D) 2-X5-cm scar present on the right lower forearm
D
Which statement best describes interpretation as a communication technique? A) Interpretation is the same as clarification B) Interpretation is a summary of a statement made by a patient C) Interpretation is used to focus on a particular aspect of what the patient has just said D) Interpretation is based on the interviewer's inference from the data that have been presented
D
Which statement best describes the purpose of a health history? A) To provide an opportunity for interaction between the patient and examiner B) To provide a form for obtaining the patient's biographic information C) To document the normal and abnormal findings for a physical assessment D) To provide a database of subjective information about the patient's past and present health
D
Which would be included in the database for a new patient admission to a surgical unit? A) All subjective and objective data gathered by a health practitioner from a patient B) All objective data obtained from a patient through inspection, percussion, palpation, and auscultation C) A summary of a patient's record, including laboratory studies D) All subjective and objective data, data gathered from a patient, and the results of any laboratory or diagnostic studies completed
D
While assessing a man for allergies, he states he is allergic to penicillin. Which response is best? A) Are you allergic to any other drugs? B) How often have you received penicillin? C) I'll write your allergy on your chart so you won't receive any D) Please describe what happens to you when you take penicillin
D
You are assessing short-term cognitive function. Which assessment shows the ability to lay down new memories? A) Noting whether the patient completes a thought without wandering B) A test of general knowledge C) A description of past medical history D) use of the Four Unrelated Words Test
D
You assess a patient who has 4+ edema of the right leg. What is the best way to document this finding? A) Mild pitting, no perceptible swelling of the leg B) Moderate pitting, indentation subsides rapidly C) Deep pitting, leg looks swollen D) Very deep pitting, indentation lasts a long time
D
You note a lesion during a skin assessment. Which is the best way to document this finding? A) raised, irregular lesion the size of a quarter, located on dorsum of left hand B) Open lesion with no drainage or odor, approximately 1/4 inch in diameter C) Pedunculate lesion below left scapula with consistent red color and no drainage or odor D) Dark brown raised lesion, with irregular border, on dorsum of right foot, 3 cm in size, with no drainage
D
You will use which technique when assessing an older individual who has cognitive impairment? A. ask open-ended questions B. complete the entire assessment in one session C. ask the family members for information instead of the older individual D. ask simple questions that have "yes" or "no" answers
D
A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? A) Acne B) Warts C) Psoriasis D) Herpes simplex E) Varicella
D E
After examining a patient, you note: fever, increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with: A)Bronchitis B) Asthma C) Pleural effusion D) Lobar pneumonia
D) Lobar pneumonia
On auscultating a patient, you note a coarse, low-pitched sound during both inspiration and expiration. This patients report pain with breathing. These findings are consistent with: A) Fine crackles B) Wheezes C) Atelectatic crackles D) Pleural friction rub
D) Pleural friction rub
Normal chest
Elliptic shape with an anteroposterior to transverse diameter in the ratio of 1:2
Kyphosis
Exaggerated posterior curvature of thoracic spine
Euphoria
Excessive well-being
Location - Lateral Right Lung Border
Fifth intercostal
Pectus carinatum
Forward protrusion of the sternum with ribs sloping back at either side
Jaundice
Increase in bilirubin in the blood causing a yellow color in the skin
Flat affect
Lack of emotional response
Scoliosis
Lateral S-shaped curvature of the thoracic and lumbar spines
Rage
Loss of control
Depersonalization
Loss of identity
Lability
Rapid shift of emotions
Location - Base of Lung
Rests on the diaphragm
what is SBAR?
S: Situation B: Background A: Assessment R: Recommendation
Depression
Sad, gloomy, dejected
Location - Lateral Left Lung Border
Sixth rib, midclavicular line
Pectus excavatum
Sunken sternum and adjacent cartilages
suprasternal notch
U shaped depression just above sternum between clavicles
Fear
Worried about known external danger
what is the thoracic cage?
a bony structure with a conical shape, which is narrower at the top - defined by sternum, 12 pairs of ribs, and 12 thoracic vertebrae
what is a pulse oximeter?
a noninvasive method to assess oxygen saturation - detector measures relative amount of light absorbed by HbO2 and unoxygenated Hb
what is perception?
a person should be consistently aware of reality; receptions should be congruent with yours
define mental status
a person's emotional and cognitive functioning - cannot be scrutinized directly
what is a linear lesion?
a scratch, streak, line, or stripe
atelectatic crackles
a type of adventitious sound that is not pathologic - short, popping, crackling sounds that sound like fine crackles by do not last beyond a few breaths
what are the five components of the jugular pulse?
a wave, c wave, x wave, v wave, y descent
what are ADLs?
activities for daily living including eating, bathing, grooming, etc.
what are AADLs?
activities older adults perform as family member, member of society and community, including occupational and recreational activities
what happens to temperature in the aging adult?
aging person is less likely to have a fever, but at greater risk for hypothermia - temperature is a less reliable index of older person's true health state and sweat glad activity is diminished
manubriosternal angle
angle of louis - at articulation of manubrium and sternum and continuous with second rib - site of tracheal bifurcation
what is a polycyclic lesion?
annular lesions that grow together
Barrel chest
anteroposterior = transverse diameter
what happens to blood pressure in an aging adult?
aorta and major arteries tend to harden, systolic pressure increases leading to widened pulse pressure - many older people have higher both pressure
what areas on the heart do you auscultate?
aortic area, pulmonic area, erb's point, tricuspid area, and mitral area
what are the two semilunar (SL) valves?
aortic valve - left SL valve pulmonic valve - right SL valve
what is a collaborative problem?
approach to treatment involve multiple disciplines
precordium
area on anterior chest overlying heart and great vessels
what are the steps of the nursing process?
assessment, diagnosis, planning, implementing, and evaluation.
To use the technique of egophony, ask the patient to: a) take several deep breaths and then hold for 5 seconds b) say "eeeee" each time the stethoscope is moved c) repeat the phrase "ninety-nine" each time the stethoscope is moved d) whisper a phrase as auscultation is performed
b) say "eeeee" each time the stethoscope is moved
what are three types of malignant skin lesions?
basal cell carcinoma, squamous cell carcinoma, malignant melanoma
what is an annular or circular lesion?
begins in the center and spreads to periphery
keloids
benign excess of scar tissue beyond original injury
what makes up clinical decision making?
best evidence from literature + patient's own preference + clinician's experience/expertise + physical exam
sternum
breastbone - manubrium, body, and xiphoid process
what is a reason for seeking care?
brief spontaneous statement in person's own words describing reason for visit
what are the five factors that determine level of blood pressure?
cardiac output - increase leads to increase in bp peripheral vascular resistance - increased leads to increase in bp volume of circulating blood - fluid retention leads to increased bp where hemorrhages leads to decreased bp viscosity - increased associated with increase in bp elasticity of vessel walls - increase rigidity associated with increase in bp
define mental disorder
clinically significant behavioral emotional or cognitive syndrome that is associated with significant distress or disability involving social, occupational, or key activities
what is a grouped lesion?
clusters of lesions
what is an episodic or problem-centered database?
collect "mini" database, smaller scope and more focused than complete database
what should you note if you any lesions are present?
color, elevation, pattern or shape, size, location + distribution, any exudate
what do you look for during inspection + palpation of the skin?
color, temperature, moisture, texture, thickness, edema, mobility + turgor, vascularity or bruising, and presence of lesions
scale
compact flakes of desiccated skin from shedding of dead excess keratin cells
spinous processes
count down these knobs on vertebrae, which stack together to form spinal column
what happens to respirations in an aging adult?
decrease in vital capacity and decreased inspiratory reserve volume - shallower inspiration phase and increased respiratory rate
what leads to low readings of bp?
decreased inflation too large cuff size
aging adult + respiration
decreased vital capacity + increased residual volume based on structural changes - histologic changes lead to decreased gas exchange
ulcers
deeper depression extending into dermis with irregular shape, may blood, leaves scar
what is a complete total health database?
describes current and past health state and forms baseline to measure all future changes
what is the difference between the diaphragm and the bell on a stethoscope?
diaphragm - flat edge, high pitched sounds bell - deep, hollow cup shaped, soft pitched sounds
what is a discrete lesion?
distinct and separate
define organic disorder
due to brain disease of known specific organic causes (e.g., delirium, dementia, intoxication, and withdrawal)
what are the difference types of sweat glands?
eccrine - produces sweat apocrine - produces milky secretion + open into hair follicles
what is diastolic pressure?
elastic recoil, or resting, pressure that blood exerts constantly between each contraction
vesicles
elevated cavity containing fluid up to 1cm
what is a first-level priority?
emergent, life threatening, and immediate
cysts
encapsulated fluid filled cavity
what is the structure of the skin?
epidermis + dermis with a subcutaneous layer of adipose tissue
what is a review of systems (ROS)?
evaluate past + present state of each body system. assess that all pertinent data relative to each body system have been noted. evaluate health promotion practices - does NOT include objective data
papules
felt and caused by superficial thickening of the epidermis
what are the different parts of the hands best suited for assessing when palpating?
fingertips: fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps fingers+thumbs: detection of position, shape, and consistency of an organ or mass dorsa of hands and fingers: determining temperature base of fingers or ulnar surface of hand: best for vibration
vertebra prominens
flex your head and feel for most prominent bony spur protruding at base of neck
what is social domain?
focuses on relationships within family, social groups, and community
what is blood pressure?
force of blood pushing against side of its container, vessel wall
pleurae
form an envelope between lungs and chest wall - visceral pleura lines outside of lungs dipping into fissures - pleural cavity normally has a vacuum - potential space filled with only a few milliliters of fluid
how are heart sounds described?
frequency or pitch intensity or loudness duration timing
acinus
functional unit consists of bronchioles, alveolar ducts, alveolar sacs and alveoli
cardiac output
heart normally pumps between 4 and 6L of blood per minute CO = HR X SV
systole
heart's contraction, blood pumped from ventricles fill pulmonary and systemic arteries
how do you engage in percussion?
hyperextend the middle finger placing only the distal joint and tip against a person's skin use the middle finger of the dominate hand to strike so the tip makes contact
what is third-level priority?
important to patient's health but can be addressed after more urgent problems are addressed
what is the difference between informal and formal support networks?
informal includes family and close long-time friends and is usually free of charge, formal supports include programs such as social welfare and healthcare delivery agencies
what is the order of assessment?
inspection palpation percussion auscultation UNLESS ABDOMEN
what is evidence-based practice (EBP)?
integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences
Erythema
intense redness of the skin due to excess blood in dilated superficial capillaries
what are the steps of an interview?
introducing the interview, working phase, and closing the interview with the summary as a final statement
what is the pressure/pulse changes in an aging adult?
isolated systolic htn, left ventricular wall thickening, pulse pressure increases, no change in resting heart rate or cardiac output, decrease in ability of heart to augment cardiac output with exercise
tumors
larger in diameter, firm, or soft, deeper into dermis may be benign or malignant
bullas
larger than 1 cm diameter, usually single chamber, superficial in dermis and ruptures easily
what is the duration?
length of time sound lingers
what is a confluent lesion?
lesions that run together
what is objective data for behavior?
level of consciousness, facial expression, speech, mood and affect
what is a zosteriform lesion?
linear arrangement following a unilateral nerve route
fissures
linear crack with abrupt edges extending into dermis
what are the critical characteristics of pain?
location, character or quality, quantity or severity, timing, setting, aggravating or relieving factors, associated factors, patient's perception - Remember PQRSTU
what happens to the skin in the aging adult?
loses elasticity, decreased number + function of glands, senile purpura, skin breakdown + slower healing
what is aphasia?
loss of ability to speak or write coherently or to understand speech or writing due to a cerebrovascular accident
what is amplitude (intensity)?
loud or soft sound
patches
macules that are larger than 1 cm
what is systolic pressure?
maximum pressure felt on artery during left ventricular contraction, or systole
how is skin color derived?
melanin - brown pigment carotene - yellow orange pigment red purple tones in the underlying bed
mediastinum
middle section of thoracic cavity containing esophagus, trachea, heart, and great vessels
myocardium
muscular wall of heart
what is a second-level priority?
next in urgency, requiring attention so as to avoid further deterioration
what is involved in a functional assessment?
objectively measure functional status, ADLs, relevant data related to lifestyle and type of living environment
fourth heart sound (S4)
occurs at end of diastole, at presystole, when ventricle resistant to filling - occurs just before S1
third heart sound (S3)
occurs when ventricles resistant to filling during early rapid filling phase (protodiastole) occurs immediately after S2, when AV valves open and atrial blood first pours into ventricles
first heart sound (S1)
occurs with closure of AV valves - signals beginning of systole mitral component of first sound (M1) slightly precedes tricuspid component (T1)
second heart sound (S2)
occurs with closure of semilunar valves - signals end of systole aortic component of second sound (A2) slightly precedes pulmonic component (P2)
afterload
opposing pressure ventricle must generate to open aortic valve against higher aortic pressure - resistance against which ventricle must pump its blood
what are the different ways to take a temperature?
oral, rectal, tympanic, temporal
define psychiatric mental illness
organic etiology has not yet been established, mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life
what is objective data for cognitive function?
orientation, attention span, recent memory, remote memory
what is pulse?
palpable flow felt in the periphery as a result of pressure wave generation from stroke volume
twelfth rib
palpate midway between spine and a person's side to identify its free tip
plaques
papules coalescing to form surface elevation wider than 1 cm
what is caregiver burden?
perceived strain by person who cares for an older adult, chronically ill, or disabled person
scars
permanent fibrotic change after healing
what is the four unrelated words test?
pick four words with semantic and phonetic diversity, ask for recall of four words at 5, 10, and 30 minutes
what is objective data for appearance?
posture, body movements, dress, grooming and hygiene
what happens with dysrhythmias and aging?
presence of supraventricular and ventricular dysrhythmias increase with age, ectopic beats are common, tachyarrhythmias are not tolerated as well
what is mean arterial pressure (MAP)?
pressure forcing blood into tissues, averaged over cardiac cycle
lichenifications
prolonged intense scratching leads to thickened skin producing tightly packed set of papules
what is the function of the skin?
protection from environment prevents penetration Perception temperature regulation identification communication wound repair absorption and excretion production of vitamin D
pustules
pus in cavity that is circumscribed and elevated
what is an emergency database?
rapid collection of data often compiled concurrently with lifesaving measures
what is a target or iris lesion?
resembles iris of eyes, concentric rings
atrophic scars
resulting skin level is depressed with loss of tissue and thinning
what happens to pulse in an aging adult?
rhythm may be slightly irregular, radial artery may feel stiff, rigid, + tortuous in older person, increasingly arterial wall needs faster upstroke of blood so pulse is easier to palpate
differences in right and left lungs
right lung shorter because of underlying liver - left lung narrower because heart bulges to left - right lung has three lobes and left lung has two lobes
inferior border of scapula
scapulae are located symmetrically in each hemothorax
erosions
scooped out by shallow depression
what is sebum?
secreted lipid substance through hair follicles - sebaceous glands
excoriations
self-inflicted abrasion that is superficial
what are the characteristics of the carotid artery pulse waveform?
smooth rapid upstroke, summit rounded and smooth, downstroke more gradual and has a dicrotic notch caused by closure of aortic valve
macules
solely a color change, flat and circumscribed, of less than 1 cm
nodules
solid, elevated, har or soft, greater than 1 cm may extend deeper into dermis than papule
what are the related organs of the lymphatic system?
spleen, tonsils, and thymus
what is a follow-up database?
status of all identified problems should be evaluated at regular and appropriate intervals
what is a general survey?
study of the whole person, covering the general health state and any obvious physical characteristics
what forms a patient's database?
subjective data + objective data + patient's record + laboratory studies
what is the quality (timbre)?
subjective difference
wheals
superficial, raised, transient, and erythematous; slightly irregular shape from edema
four major functions of respiratory system
supplying oxygen to the body for energy production, removing carbon dioxide as a waste products of energy reactions, maintaining homeostasis of arterial blood, maintaining heat exchange
what is the difference between a symptom and a sign?
symptom: subjective sensation person feels from disorder documented in quotes sign: objective abnormality that can be detected on physical examination or in laboratory reports
what is orthostatic (postural) vital signs?
take serial measurements of pulse and blood pressure
what leads to high readings of bp?
taking when physiologically active, following activity, or emotionally labile narrow cuff size and/or applied too loose re-inflating during procedure
what does vital signs include?
temperature, pulse, respiration, blood pressure
what is judgement?
the ability to compare and evaluate alternatives and reach an appropriate course of action
Which of the following is a good example of a well-written chief complaint? 1.Patient complaining of chest pain for about 3 days that is worse with activity and relieved with rest. 2.Pain is a 10/10. 3.Patient complaining of chest pain. R/O MI. 4.Patient states "I don't know what this pain is. This is the worst I have ever felt."
the correct answer is 1
The nurse has a "hunch" that the patient's elevated blood pressure is due to pain level; however, the patient received blood pressure and pain medication 45 minutes ago. What should the nurse consider in regards to this hunch? 1.Research supports that the pain and blood pressure medications will take 30 minutes to become effective. The nurse should wait until the next prescribed time and reevaluate pain level. 2.The nurse should consider consulting with the pain management team to evaluate the effectiveness of the pain medication regimen. 3.The nurse should disregard the hunch because hunches are not effective at incorporating evidence-based practices. 4.The nurse should administer pain medication based on the hunch.
the correct answer is 2
The nurse is preparing to do a physical assessment on a patient who is end-stage HIV positive. What should the nurse do for self-protection? 1.Wash hands and don gloves, gown, and protective face shield. 2.Don gloves and wash hands after examination; no other protective equipment is necessary. 3.Wash hands and don two pairs of gloves and gown. 4.Wash hands, don gloves, and wash hands after examination; no other protective equipment is necessary.
the correct answer is 4
what is the pulse pressure?
the difference between systolic and diastolic blood pressure
what is the strength of pulse?
the force of pulse is strength of heart's stroke volume 3+-0 scale
what are the interview contract terms?
the location, explanation, purpose, time frame, participation, confidentiality, and cost
what is pitch (frequency)?
the number of vibrations per second
costal angle
the right and left costal margins form an angle where they meet at the xiphoid process
what is thought processes?
the way a person thinks should be logical, goal directed, coherent, and relevant. should be complete thoughts
crust
thickened dried out exudate
endocardium
thin layer of endothelial tissue that lines inner surface of heart chambers and valves
what should you listen for when listening to murmurs?
timing, loudness, pitch, pattern, quality, location, radiation posture and change of position
what is the purpose of the health history?
to collect subjective data about patients: biographic data, reason for seeking care, past and present health, family history, review of systems, function assessment, and perception of health
what is the function of the lymphatic system?
to conserve fluid and plasma proteins that leak out of capillaries and from a major part of immune system that defends body against disease, and absorb lipids from intestinal tract
what is the function of veins?
to drain deoxygenated blood and its waste products from tissues and return it to the heart
what is the function of arteries?
to supply oxygen and essential nutrients to tissues
pericardium
tough, fibrous, double-walled sac that surrounds and protects heart
what are the two atrioventricular (AV) valves?
tricuspid - right AV valve bicuspid or mitral - left AV valve
what is a gyrate lesion?
twisted, coiled, or snakelike
what are some conditions that can result in murmers?
velocity of blood increases viscosity of blood decreases structural defects in valves
preload
venous return that builds during diastole
diastole
ventricles relax and fill with blood
what is though content?
what a person says should be consistent and logical
urticaria
wheals coalesce to form extensive reaction, intensely pruritic
when do you take thigh pressure?
when the bp at the arm is excessively hight, compare it to the thigh to check for coarctation of aorta - normally systolic is higher in the thigh
