Health Assessment Test 1

Cornea

part of refracting media of eye, bending incoming light rays so that they will be focused on inner retina

Lacrimal apparatus

provides irrigation to the eye.

Ear test procedure

pull up and back -insert 1 to 1.5 cm

ausculation means...

listening to sounds made by body (use stethoscope)

Conductive hearing loss

mechanical dysfunction of external or middle ear

Two trapezius muscles

move shoulders and extend and turn head.

hypoglossal cranial nerve (CN XII)

movement of tongue Test: Light, tight, dynamite

Pupillary light reflex

normal constriction of pupils when bright light shines on retina

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect? 1. Pale mucosa 2. Bright red mucosa 3. Green discharge 4. Yellow discharge

pale mucosa

pneumothorax

air in the pleural cavity causing lung to collapse

bronchial breath sounds

anteriorly over trachea - loud, high pitched, hallow sound

Optic disc

area in which fibers from retina converge to form optic nerve

cyanosis

blueish- decreased oxygenation

Outer one third of canal is _______

cartilage

Iris

functions as a diaphragm, varying opening at its center, the pupil

Crackles in the lungs

wet popping sounds when air is moving through liquid - collapsed alveoli

Tympanic Membrane (TM)

Also called the eardrum, separates external and middle ear -Translucent membrane with a pearly gray color

Eye: a sphere of three concentric coats

(1) the outer fibrous sclera, (2) the middle vascular choroid, (3) the inner nervous retina

Sutures—adjacent cranial bones mesh at sutures

- Coronal - Sagittal - Lambdoid

Other than detecting physical abnormalities, what benefits are there to performing a complete physical exam

- Establish therapeutic relationship -Educate and promote health

Facial cranial nerve (CN VII)

- Symmetry of facial expressions and test anterior 2/3 of the tongue for ability to taste

Endocrine gland

-straddles trachea in middle of the neck -Thyroxine (T4) and triiodothyronine (T3), which are hormones that stimulate rate of cellular metabolism

Gordon's Functional Health Patterns

1) Health Perception - Health Management Pattern 2) Nutritional - Metabolic Pattern 3) Elimination Pattern 4)Activity - Exercise 5) Pattern Cognitive - Perceptual Pattern 6) Sleep - Rest Pattern 7) Self-perception - Self-concept Pattern 8) Role - Relationship Pattern 9) Sexuality - Reproductive Pattern 10) Coping - Stress Tolerance Pattern 11) Value - Belief Pattern

Using an otoscope

1) make sure it is changed 2) Attack head to handle 3) Attach and twist deposable speculum to head 4) Turn on the light 5) handle the otoscope carefully and safety 6)Discharge speculum

A nurse is assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client? (select all that apply) 1. "Are you experiencing difficulty breathing?" 2."How long has the lump been on your neck?" 3."Is the lump causing you discomfort?" 4."Are you having difficulty swallowing?" 5."Have you started taking a new medication?"

1. "Are you experiencing difficulty breathing?" 2."How long has the lump been on your neck?" 3."Is the lump causing you discomfort?" 4."Are you having difficulty swallowing?"

A nurse is preparing to assess a client's conjunctiva. Identify the sequence the nurse should follow when taking the following actions

1. Apply examination gloves 2. Instruct the client to look up 3.Place the thumbs below each of the client's lower eyelids. 4. Gently pull the client's skin down to the top edge of the bony orbital rim 5. Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions

pulse points

1. Common carotid 2. Brachial 3. Radial 4. Femoral 5. Feet

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears? (select all that apply) 1. Have you had trouble hearing? 2. Do you ever lose your balance? 3. Have you ever used hearing aids? 4. Do you have ringing in your ears? 5. Do you have a problems with nasal drainage?

1. Have you had trouble hearing? 2. Do you ever lose your balance? 3. Have you ever used hearing aids? 4. Do you have ringing in your ears?

A nurse is caring for a client who had a suspected stroke? Which of the following actions should the nurse take? (Select all that apply) 1. Make the client NPO. 2.Assess the client's orientation. 3.Check cranial nerves I, II, and V. 4.Inspect the client's muscular symmetry.

1. Make the client NPO 2. Assess the client's orientation

A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding? (Select all that apply) 1. Oval white patches in the client's hair 2.A lesion on the client's scalp 3.Protrusion of the client's head 4.Edema around the client's eyes 5.Protrusion of the client's mastoid bone

1. Oval white patches in the client's hair 2.A lesion on the client's scalp 3.Protrusion of the client's head 4.Edema around the client's eyes

A nurse is preparing to palpate a client's sinuses. Identify the sequence the nurse should follow when taking the following actions.

1. Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the clients frontal sinuses is the first step 2. Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes is the second step 3. Ask the client if they detect tenderness or pain is the third step 4. Position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses. 5. Apply firm, upward pressure and ask the client if hey detect tenderness or pain

A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations preformed on a regular basis? (Select all that apply) 1.Vision screening every year 2.Hearing test every 5 years 3.Dental examination every 6 months' 4.Skin cancer screening every 2 years 5.Neurological check every 3 months

1.Vision screening every year 3.Dental examination every 6 months

Adult respiratory rate

12-20 breaths/min

Heart rate of adult

60-100 bpm

Cone of light should be visable at

7:00 in left ear and 5:00 in right ear

Auditory canal

A cul-de-sac 2.5 to 3 cm long in adults that terminates at eardrum, or tympanic membrane -Lined with glands that secrete cerumen, a yellow waxy material that lubricates and protects ear

AVPU scale

A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process.

Who would we treat first A) 48 year old w chest pain B) 19 yr old with headaches and stable vital signs C) 68 yr who had a ground level fall

A) 48 year old w chest pain

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the clients breathing. The nurse should identify this observation as which of the following findings A) crackles B) Stridor C) Wheezes D) Friction rub

A) Crackles

Trigeminal cranial nerve (CN V)

Ability to bite and chew - sensation of skin on the face

Age-related macular degeneration (AMD)

Or breakdown of cells in macula of retina; loss of central vision

Lacrimal Apparatus

Ask the person to look down; with thumbs, slide outer part of upper lid up along bony orbit to expose under lid; inspect for any redness or swelling.

conjunctiva and sclera inspection

Ask the person to look up; using thumbs, slide lower lids down along orbital rim, being careful not to push against eyeball.

Lips and mouth

Asses for mouth and lip color, symmetry, dryness, and cracking

Speculum

Available in 2 sizes: 2-mm for peds and 4mm for adult

Culture and genetics

Awareness of the emerging minority - Diversity and incorporation of "cultural health rights"

A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first? A) Auscultation B) Inspection C) Percussion D) palpation

B) Inspection

A nurse is performing a physical examination of the spine for an older adult client. The client should identify that which of the following findings is common with aging A) Lordosis B) Kyphosis C) Ankylosis D) Scoliosis

B) Kyphosis Lordosis- swayback Kyphosis- hunchback Ankylosis-immobility Scoliosis- lateral curve

Is bell or diagram used for heart murmurs and bruits

Bell

Pilar cyst (Wen)

Benign growth that presents as smooth, fluctuant swelling on scalp

Balance exams

Both musculoskeletal and neurological exam - Romberg test

Glaucoma

Or increased intraocular pressure; chronic open-angle glaucoma is most common type

A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the tip of a clients foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses A) Posterior tibial B) Popliteal C) Dorsalis pedis D) Femoral

C) Dorsalis pedis

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the clients abdomen should the nurse attempt to auscultate active bowel sounds first A) RUQ B) LUQ C) RLQ D) LLQ

C) RLQ

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? A) A continuous sensation of vibration felt over the second and third left intercostal spaces B) A high pitched scraping sound heard in the third intercostal space to the left of the sternum C)A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line D) A whooshing or swishing should over the seconds intercostal space along the left sternal border

C)A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line

What nerves are checked during eye and ear

CN 2 ,3 ,4, 6, 8

Inner canthus

Caruncle is small fleshy mass containing sebaceous glands

Most common causes of decreased visual functioning in older adults are the following:

Cataract -glaucoma -age related macular degeneration - Diabetic retinopathy

Olfactory Cranial nerve (CN 1)

Check for recognizing familiar scent

Parkinson syndrome

Classic "maskline" appearance, elevated eyebrows, staring gaze, oily skin and drooling due to dopamine deficiency

Cushing syndrome

Classic "moonlike" face, red cheeks, and hirsutism

Test visual fields

Confrontation test

Movement of the extraocular muscles stimulated by three cranial nerves

Cranial nerve VI: abducens nerve, innervates lateral rectus muscle, which abducts eye Cranial nerve IV: trochlear nerve, innervates superior oblique muscle Cranial nerve III: oculomotor nerve, innervates all the rest: the superior, inferior, and medial rectus and the inferior oblique muscles

What evaluates facial symmetry

Cranial nerve VII- ask client to smile and puff out cheeks

A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve 1 is intact a) The client can stick their tongue out b) The client can smile symmetrically C) The client can hear whispered words D) The client can identify a minty scent

D) The client can identify a minty scent

A nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics? a) Gait B) hearing C) Vision D) balance

D) balance

A nurse is performing a general client survey and finds that the client has a BMI of 23. Which of the following should the nurse document. A) no nutritional issues B) High risk for obesity C) The client will need referral to a dietitian D)The client has a BMI within the expected range

D)The client has a BMI within the expected range

A nurse is assessing an older adult clients mouth. The nurse should identify that which of the following is an expected variation for this client 1.Yellowing of the hard palate 2. Red spots on the hard palate 3. White patches not he Tonge 4. Darkening of the mucosa

Darkening of the mucosa

Evidence-based practice and assessment-

Evidence-based practice (EBP) - -Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences -Clinical decision making = best evidence from literature review + patient's own preference + clinician's experience/expertise + physical exam

Otoscopic examination

External canal—redness or swelling - Cerumen discharge, foreign bodies, or lesions

Ophthalmoscope

Eyes, red reflex

Facial expression

Facial expressions formed by facial muscles

Priority Problems Level

First-level priority -Emergent, life threatening Second-level priority -avoid deterioration Third-level priority - not very urgent Collaborative problems -multiple disciplines

Conjugate movement.

Four straight, or rectus, muscles are superior, inferior, lateral, and medial rectus muscles. • Two slanting, or oblique, muscles are superior and inferior muscles.

Cranial bones

Frontal Parietal Occipital Temporal

Health promotion and disease prevention

Guide to Clinical Preventive Services—annual update

Sternomastoid enables

Head rotation and flexion and divides each side of neck into two triangles: anterior and posterior triangles

Anthropometric measurements

Height, weight, bmi

Holistic model assessment

Incorporation of impact of external and interpersonal environment on one's mind and body

Peripheral vascular assessment

Inspect lower extremities for color, edema, shiny

Abdominal examination

Inspect skin, contour, umbilics, pulsation and hair distribution -Auscultate for bowel sounds and bruits - percuss abdomen -palpate for rigidity, masses, and tenderness

Otoscope

Instrument used to examine ears and tympanic membranes

Murmurs grading

Intensity (loudness) 1 = faint 6 = extremely loud (heard with a stethoscope even when slightly REMOVED from the chest)

nystagmus

Involuntary rapid eye movements

Equilibrium

Labyrinth in inner ear constantly feeds information to brain about body's position in space.

Diabetic retinopathy

Leading cause of blindness in adults ages 25 to 74 years of age

Jaundice

Liver issue

Pallor

Loss of color

Rhonchi

Low pitched wheeze

Rinne test

Normal finding—AC greater than BC, noted as positive finding Abnormal finding relates to:• Sensorineural loss: Normal ratio intact but reduced, the person hears poorly both ways

Weber test

Normal finding—sound is equally heard in both ears Abnormal finding—sound lateralizes to one ear Conductive loss—Sound lateralizes to poorer ear Sensorineural loss—Sound lateralizes to better ear

Pathways of hearing

Normal pathway of hearing is air conduction (AC) described previously; it is the most efficient. Alternate route is by bone conduction (BC). • Bones of the skull vibrate and are transmitted directly to inner ear and to cranial nerve VIII.

NANDA-

North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology

Visual impairment (VI)

Not being able to see letters on the eye chart at line 20/50 or below

Equipment needed ear exam

Otoscope with bright light, fresh batteries give off white, not yellow light. -Pneumatic bulb attachment, sometimes used with infant or young child - Tuning forks in 512 and 1024 Hz

When planning to assess the client, which of the following actions should you take to prevent activity intolerance

Perform the assessment at the same time as the clients bath

Abnormal Findings: Eyelid Abnormalities

Periorbital edema Exophthalmos (protruding eyes) Enophthalmos (sunken eyes) Ptosis (drooping upper lid) Upward palpebral slant Ectropion Lower lid rolling out Entropion Lower lid rolling inCopyright © 2020 b

Thyroid Disorders: Hypothyroidism

Physical presentation neck and face Puffy edematous face Periorbital edema Coarse facial features Coarse hair and eyebrows

Graves Disease

Physical presentation neck and face Goiter Eyelid retraction Exophthalmos

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect? 1. Ptosis of an eyelid 2.Yellow sclera 3.Edema of the eyelids 4.Reddened conjunctiva

Yellow sclera

Spinal accessory cranial nerve (CN XI)

Provide resistance, have the client turn head from side to side and shrug shoulders upward

Old people eyes

Pupil size decreases. - Presbyopia - Lens loses elasticity, becoming hard and glasslike, which decreases ability to change shape to accommodate for near vision. - By age 70, normally transparent fibers of lens begin to thicken and yellow, the beginning of cataracts. - Visual acuity may diminish gradually after age 50, and more so after age 70.

How much information should be included in a comprehensive physical exam

SBAR and SOAP -document

Cornea and Lens

Shine light from side across cornea, and check for smoothness and clarity.

_____ muscles attach eyeball to its orbit and direct eye to points of a person's interest.

Six -Give eye both straight and rotary movement.

Inspect external ear

Size and shape of auricle, position and alignment on head Note skin condition. Check auricle and tragus for tenderness. Evaluate external auditory meatus.

Major neck muscles

Sternomastoid and trapezius are innervated by cranial nerve XI.

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect? 1. White patches on the tongue 2. Beefy red tongue 3. Petechiae on hard palate 4. Overgroth og gum tissue

White patches on the tongue

Fragrance (coffee or mint)

Testing the first cranial nerve (the olfactory nerve) -test one nostril at a time -do not use alcohol wipes

Components of quality improvement:

The problem The goal The aim The measures The Analytics

Use penlight in mouth to find

Tongue blade, moistness, inflammation, ulcers, lesions, white patches. Parlor, cyanosis and jaundice are best seen here especially on dark skin tones

Conjunctiva

Transparent protective covering of the eye

Eversion of the Upper Lid

Used when one suspects foreign body or eye pain

Glossopharyngeal and vagus cranial nerve (CN IX and X)

Uvula is midline and rises - ability to swallow

Subjective eye

Vision difficulty: decreased acuity, blurring, blind spots -Pain -Strabismus - diplopia -Redness, swelling -Watering, discharge -History of ocular problems -Glaucoma -Use of glasses or contact lenses

Can I perform a general patient survey without specialized equipment?

Yes.

A nurse is preforming a focused assessment on a client who reports having difficulty swallowing and a continuous headache. The nurse should identify that these findings can indicate which of the following conditions? 1. Chest disorder 2. Thyroid disorder 3. Musculoskeletal disorder 4. Central nervous system disorder

central nervous system disorders

Nursing Diagnosis

clinical judgment that helps nurses determine the plan of care for their patients. These diagnoses drive possible interventions for the patient, family, and community.

In aging persons, cilia lining ear canal become

coarse and stiff

To the outer ear and inner ear eustachian tube: opening that

connects middle ear with nasopharynx and allows passage of air

wheezes

constricted airway. bronchial inflammation, tumors, mucous plug

Tarsal plates

contain meibomian glands, which are modified sebaceous glands that secrete an oily lubricating material onto lids.

Hirschberg test

corneal light reflex

After assessing respiratory function, reassess by making the client...

cough

A nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect? 1. Defined reddened area of the sclera 2. Dropping of the eyelid 3. Cloudy pupil 4. Bulging eyes

defined reddened area of the sclera

Is bell or diagram used for high pitched sounds such as heart, lung or bowel sounds

diagram

Glasgow Coma Scale

eyes, verbal, motor Max- 15 pts, below 8= coma

A nurse is preforming a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has a difficulty reading fine print. In which of the following sections of the client's electronic health record should the nurse document this finding? 1. Vital signs 2. Review of system 3. Allergies and home medications 4. Patient information

review of systems

Pupil

round and regular; size determined by balance between parasympathetic and sympathetic chains of autonomic nervous system

pericardial friction rub

scraping or grating noise heard on auscultation of the heart; suggestive of pericarditis

friction rub

scratching or squeaking sound when thoracic cavity is inflamed

Sensorineural (or perceptive) hearing loss:

signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex

Diagnostic Positions Test

six cardinal positions of gaze

stridor

strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx

Pen light pupillary responses provide

tangential lighting when examining skin surfaces tangential lighting: Lighting set to a low angel relative to a surface. It highlights protrusions by casting a shadow and small movements by flickering light

percussion

tapping on a surface to determine the difference in the density of the underlying structure -we want a resonance, low pitched, hallow sound

Angle of Louis

the junction between the body of the sternum and the manubrium; the starting point for locating the ribs anteriorly

palpate

to examine by touch

Skin assessment for...

- consistently, color, hair -temp, texture, moisture -turgor and edema -nails for color, shape, thickness, lesions, clubbing, capillary refill

Musculoskeletal exam

- functional assessment for safety -posture movement and symmetry - palpate spine for contour and tenderness - inspect limbs for skin changes and symmetry -palpate limbs for muscle mass, ton, strength join range of motion and crepitus -assess gait

Choroid:

has dark pigmentation to prevent light from reflecting internally and is heavily vascularized to deliver blood to retina

Vesicular breath sounds

heard over lunch tissue -soft, fine , breezy low pitched sounds

Bronchovesicular breath sounds

heard over mainstem bronchi - medium pitched quieter sounds

Client-centered care

Client-centered care is about treating clients as they want to be treated, with knowledge about and respect for their values and personal priorities.

Inspect tympanic membrane

Color, characteristics, position, and integrity

Otosclerosis

Common cause of conductive hearing loss in young adults between ages of 20 and 40 -Gradual hardening that causes footplate of stapes to become fixed in oval window

Collecting Four Types of Data

Complete total health database -Describes current and past health state and forms baseline to measure all future changes. Episodic or problem-centered database - -Collect "mini" database, smaller scope and more focused than complete database. -Follow-up database- - Status of all identified problems should be evaluated at regular and appropriate intervals. Emergency database- Rapid collection of data often compiled concurrently with lifesaving measures.

Called the auricle or pinna

Consists of movable cartilage and skin - Characteristic shape serves to funnel sound waves into its opening, which is called the external auditory canal.

A nurse has a hunch that a patient's elevated blood pressure due to pain level however the patient recieved BP and pain meds 45 min ago- what should the nurse do?

Consult with the pain management team

EOM function

Corneal light reflex, cover test, diagnostic positions test

Cranial nerve testing use a ...

Cotton ball and compare sensations bilaterally

severity of edema

Depth of indentation determines severity

A nurse is admitting a client who has had a stroke. Which of the following actions should the nurse take. 1. Keep the bedside table at the end of the client's bed 2. Place a towel not he client's bathroom floor 3. Raise the four side rails of the clients's bed 4. Keep the client's bed in the lowest position

Keep client's bed in the lowest position

Inspect ocular fundus.

Optic disc, retinal vessels, general background, and macula

Cataract formation

Or lens opacity, resulting from a clumping of proteins in lens

pulsation

a beat or throb; rhythmic vibration.

Fixation

a reflex direction of eye toward an object attracting a person's attention

Bruits

abnormal "swishing" sounds heard over organs, glands, and arteries

atelectasis

absence of breath sounds due to collapse of alveoli

Point of maximal impulse (PMI)

the point where the apex of the heart touches the anterior chest wall and heart movements are most easily observed and palpated

Retina

the visual receptive layer of eye where light waves change into nerve impulses

A nurse is preforming a head-to-toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse should identify that this finding can indicate which of the following conditions? 1. Infection 2. Cancer 3. Thyroid disorder 4. Chest disorder

thyroid disorder

Sclera

tough, protective, white covering -Continuous anteriorly with smooth, transparent cornea, which covers iris and pupil

Inner Ear

-Contains the bony labyrinth, which holds sensory organs for equilibrium and hearing. -Although the inner ear is not accessible to direct examination, its functions can be assessed

Eye exams include

- inspect eyes -check pupillary responses -Examining extraocular movement

visual acuity

- near vision (CN 2)

Respiratory assessment

- respiratory rate and rhythm -check oxygen saturation -inspect chest configuration and breathing - palpate and percuss anteriorly and posteriorly -auscultate lung sounds

What steps are important before i start a general survey

- wash hands - gather equiptment -introduce -privacy/comfort -wet lit -tell expectations

six cardinal fields of gaze

-12" away; Use finger or penlight -Have patient keep head straight and follow with eyes only -Go from center to periphery -Go clockwise -passing indicates intact oculomotor, trochlear and abducens cranial nerves 3,4, 6

Neuro test exam

-Assess mental status - Evaluate motor function, balance and coordination - Test reflexes -Assess sensory function -Test CN function

Romberg sign

-Assesses ability of vestibular apparatus in inner ear to help maintain standing balance -Also assesses intactness of cerebellum and proprioception as it is part of the neurologic system

Middle ear

-Conducts sound vibrations from outer ear to central hearing apparatus in inner ear -Protects inner ear by reducing amplitude of loud sounds -Eustachian tube allows equalization of air pressure on each side of TM so that it does not rupture.

Identify the recommendations of IOM.

-Effective policy framework and workforce planning demands an adaptable data collection systems and data infrastructural framework. -Nursing professionals should be engaged fully with other stakeholders including physicians in the process of redesigning health care in the country. -Nursing professionals should achieve advanced levels of education and capacity building through structured systems that promote seamless academic development. -Nursing professionals should optimize their practice with regards of their level of education and training

Subjective Data: head

-Headache -Head injury -Dizziness -Neck pain, limitation of motion -Lumps or swelling -History of head or neck surgery

deep tendon reflexes (DTR)

-Last part of neuro exam muscle contraction in response to a stretch caused by striking the muscle tendon with a reflex hammer. test used to determine if muscles are responding properly

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

Stethoscope

-auscultation -Bell (back) - Diagram (big part)

Are there specific considerations for conducting a general physical assessment on an older adult

-fatigue -energy level -rest -position changes -joint stiffness and pain with movement -allow more time -potential hearing or visual deficits

Tuning fork

-neuro exams -measured in hertz -High freq are used for hearing -Low frequency used for vibration

Head and neck inspection

-palpate face and skull -palpate for hair, parasites -Neck range of motion -Neck for contour and tracheal position -Palpate carotid arteries -Palpate cervical lymphnodes -Visual acuity -Nerve function

Monofilament

-test for sensation Diabetic feet skin

Muscle strength scale

0 No detection of muscular contraction 1 A barely detectable flicker or trace of contraction with observation or palpation 2 Active movement of body part with elimination of gravity 3 Active movement against gravity only and not against resistance 4 Active movement against gravity and some resistance 5 Active movement against full resistance without evident fatigue (normal muscle strength)

A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify that which of t the following findings indicates the client might have. Skull fracture? 1. Edema 2. Bloody drainage 3. yellow drainage 4. crushed skin

2. Bloody drainage

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect? 1. White patches not he tongue 2. Bleeding of the gums 3. Beefy red tongue 4. Petechiae of the hard palate

3. Beefy red tongue

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include A) Insert the earpieces at the downward angle towards your nose B) Use the diaphragm to listen to low pitched sounds C) Drape the stethoscope over your neck when not in use D) Clean the stethoscope by immersing it in soapy water

A) Insert the earpieces at the downward angle towards your nose

A nurse is palpating a tender area on a clients abdomen. The nurse slowly applied pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document. A) Borborygmi B) Rebound tenderness C) Tympany D) Abdominal guarding

B) Rebound tenderness

A Nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first? a) Document accurate data B) develop a plan of care C) Validate previous data D) Evaluate outcomes of care

B) develop a plan of care

Lymphatic System

Detects and eliminates foreign substances from body -Helps to prevent potentially harmful substances from entering the circulation

Subjective Data ear

Earache Infections Discharge Hearing loss Environmental noise Tinnitus Vertigo Patient-centered care

Palpebral fissure

Elliptical open space between eyelids

Acromegaly

Elongated head, massive face, overgrowth of nose, lower jaw, heavy eyebrow ridge, and coarse facial features

A nurse is performing a head and neck assessment on a client. The client reports a high-pitched ringing in their ears. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding? 1. Encounter 2. Vital signs 3. Patient information 4. Allergies and home medications

Encounter

Simple diffuse goiter (SDG)

Endemic goiter due to iodine deficiency that results in chronic enlargement of the thyroid gland

Jugular Venous Distention

Engorged appearance of jugular veins seen when pressure on the right side of the heart is elevated.

A nurse is preforming an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye? 1. Outer layer of the eyeball 2. Mucous membrane that lines the eyeball 3. Transparent layer that covers the iris and pupil 4. Colored portion in the center of the eye

transparent layer that covers the iris and pupil

Sound waves produce vibrations on_______

tympanic membrane

Presbycusis

type of hearing loss that occurs with aging, even in people living in quiet environment

Snellen chart

used to measure visual acuity of FAR vision

if clients heart rate is irregular you need to... ?

you need to assess pulse deficit (difference between radial pulse and apical pulse) - 2 or more beats is bad bad