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