Health Assessment Exam 2: Week 3 +4

ABCT / components of the mental status exam

1. appearance 2. behavior 3. cognition 4.thought process

cervical chain

1.) superficial 2.) deep 3.) posterior *palpate sternocleidomastoid muscle*

cranial nerves

12 pairs of nerves that carry messages to and from the brain.

Hypothyroidism

A disorder caused by a thyroid gland that is slower and less productive than normal. -Can cause thin/patchy hair -intolerance to cold, preference for warm clothing, decreased sweating.

Braden Scale

A tool for predicting pressure ulcer risk -sensory perception, moisture, activity, mobility, nutrition, friction and shear. -the HIGHER the score, the LOWER the risk for pressure ulcers

vellus hair

Also known as lanugo hair; short, fine, unpigmented downy hair that appears on the body, with the exception of the palms of the hands and the soles of the feet.

alopecia areata

Autoimmune disorder that causes the affected hair follicles to be mistakenly attacked by a person's own immune system; usually begins with one or more small, round, smooth bald patches on the scalp.

What are bruits?

Bruits are the sounds made in an artery or vein when blood flow becomes turbulent or flows at an abnormal speed. -low pitched, soft swooshing/blowing sound. Best heard with bell of stethoscope. -If heard in carotid artery, could be sign of stroke!

Hirtuism

Excessive hair growth on the face, arms, and legs, especially in women.

stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, tendon, or muscle

Hypoxia

Low oxygen saturation of the body, not enough oxygen in the blood -Can result in clubbing of nails (180 degree angle)

signs of a normal lymph node

Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and non tender.

stage 2 pressure ulcer

Skin no longer intact, fleshy pink base with a break in skin integrity. Partial-thickness loss. -This is where Blistering is

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers.

Vescicles

Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. -Examples of vesicles include: herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

stage 3 pressure ulcer

Yellow fatty tissue seen at the base

cyanosis

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had...

a recent illness. (bleu lines can be a result of recent acute illness and eventually grow out)

How long does it take to totally replace a nail?

about 6 months

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is...

blue.

Psoriasis

chronic, recurrent dermatosis marked by itchy, scaly, red plaques covered by silvery gray scales. -can result in small pits on surfaces of nails. -worsens in the winter -usually on lower extremities

A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should the nurse do?

consider admitting patient to the hospital (because the red marks do not blanch).

Scabies

contagious skin disease transmitted by the itch mite, commonly through sexual contact.

The nurse suspects that a client has recently experienced emotional abuse. What did the nurse assess to make this clinical determination? Select all that apply...

crying, questioning if it really happened, avoiding eye contact, confused.

central cyanosis

decreased oxygenation, of the arterial blood in the lungs; appears as a bluish tinge of the conjunctivae, mucous membranes of the mouth and tongue; desaturation of hemoglobin. -bluish or darkened discoloration of the nail beds, earlobes, lips or toes; may be indicative of impaired lung function or a right to left shunt in congenital heart conditions.

acromegaly

enlargement of the extremities. The The skull and facial bones are larger and thicker in acromegaly.

Macules

flat spots on the skin, such as freckles

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

have a nurse who is the same sex as the client examine him.

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

if it is fixed to underlying tissue. A fixed lymph node can be seen in metastatic disease.

A nurse is providing care to a female client with a history of Cushing's disease. What findings should the nurse expect with this client?

increased body and facial hair.

Meningitis

inflammation of the meninges of the brain and spinal cord. Can cause neck pain + headache, along with a fever. (serious illness).

Stage 1 pressure ulcer

intact skin with nonblanchable redness

During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition?

iron deficiency anemia (involves spoon nails or nails that are thin and concave)

The nurse plans to administer the CAGE Self-Assessment tool on a client. The nurse explains to the client how and when the tool is used by stating which of the following?

it is a short tool used to identify people at risk for substance abuse disorder. It consists of 4 questions.

primary lesions

lesions arising from previously normal skin. (maculae, papules, nodules, tumors, polyps, wheals, blisters, cysts, postules, vesicles, abscesses).

secondary lesions

lesions that result in changes in primary lesions. Skin damage. (scar tissue, crusts from dried burns, etc.)

periphreal cyanosis

occurs when cutaneous blood flow decreases and slows and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a response to anxiety or a cold environment.

List the cranial nerves in order

olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, (acoustic) vestibulocochlear, glossopharyngeal, vagus, accessory, hypoglossal

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

oral mucosa

Epidermis

outermost layer of skin

Headaches

pain anywhere in the cranial cavity (a.k.a. cephalalgia).

pressure ulcer causes

pressure, shearing forces, friction, moisture

Papules

raised/elevated lesions, palpable, solid masses smaller than 1 cm.

sternomastoid muscle

rotates and flexes head; the cervical chain is found over this muscle.

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

sebum production

dermis

second layer of skin, holding blood vessels, nerve endings, sweat glands, and hair follicles.

Lice

small insects that attach to hair and feed on human blood -The closer to the scalp the nits are, the more recent the infestation.

Outermost layer of epidermis

stratum corneum