unit 1 quiz for hollistics
What are the normal variations of BP?
- BP varies with age (tends to rise as we age) - Sex (after puberty, females usually have lower BP than males) - Race - Diurnal rhythm (BP climbs to a high in late afternoon or early evening; BP declines in early morning) - Weight (usually higher in overweight/obese patients) - Exercise (BP is higher during and right after exercise) - Emotions (BP is higher during fear, anger, pain, stress)
Appropriate procedure and nursing considerations for assessing BMI
- Measurements you need: weight, height - Formula: weight (lbs)/height(in2 )x703 OR weight(kg)/height(m2) Considerations: - BMI expresses relationship between weight and height but does not take into consideration other variables (muscle mass) so BMI should be used in conjunction with other measures like waist circumference - If repeated weigh-ins are necessary, aim for about the same time each day and similar clothing (in morning, after bathroom, and before 1st meal)
A woman is discussing the problems she is having with her 2-year-old son. She says, "He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens." Which is the best response by the nurse to gain a better understanding of the problem?
"Fits? Tell me what you mean by this."
What are some nonverbal indications of pain?
Facial grimace, bracing, lying still, clenching teeth, frowning, Restlessness, inability to pay attention, or inability to stay still Observe: Swelling, bruising, inflammation Increased heart rate, or increased BP
What's the normal range for respirations?
For adults: 12-20 (ATI) 10-20 (Jarvis) Normal quality: regular, effortless/relaxed, silent
Appropriate procedure and nursing considerations for doing a general survey
Perform a quick overall assessment of patient and note any body system issues that will require a more focused assessment
While measuring a patients blood pressure, the nurse should recall that which is a factor that influences a patients blood pressure?
Peripheral vascular resistance
What are the normal variations of pulse?
Pulse can be affected by many factors: Body position, age, activity level, health conditions, body temp, meds Ex: pulse increases with exercise and increased body temp Pulse decreases w/ many conditions like hypothyroidism (and also in very fit people)
A nurse is at a health fair is assessing the weight status of four clients. Which of the following are classified as overweight?
a male client who has a body mass index of 29
A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?
a small, translucent papule with rolled borders
While measuring a patient's blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading?
a. the person supports his or her own arm during the blood pressure reading b. the blood pressure cuff is too narrow for the extremity d. the cuff is loosely wrapped around the arm e. the person is sitting with his or her legs crossed
What 4 things are considered in the general survey?
- Physical appearance (age, sexual development, LOC, skin color, facial feature symmetry) - Body Structure (stature, nutrition/weight/body fat, symmetry, posture, body build and contour, and any obvious deformities) - Mobility (gait, range of motion) - Behavior (speech, mood/affect, personal hygiene, facial expressions, dress)
What are the normal variations of temp?
- Temp is higher during exercise - Diurnal cycle - increased temp during menstruation - Age (usually lower in older adults)
secondary skin lesion scar
-After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue collagen. This is a permanent change -examples: healed area from surgery or injury or acne
secondary skin lesion scale
-Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin skin. -Example: After drug reaction (laminated sheets), psoriasis (silver, micalike), seborrheic dermatitis (yellow, greasy), eczema, (large, adherent, laminated), dry skin
Secondary Skin Lesion: Ulcer
-Deeper depression extending into the dermis, irregular shape, may bleed, leave scars when healed. -Examples :stasis ulcer, pressure sore, chancre
primary skin lesion vesicle
-Elevated cavity containing free fluid, up to 1CM -Examples: herpes simplex early varicella (chickenpox) herpes zoster (shingles) contact dermatitis
primary skin lesion cyst
-Encapsulated fluid filled cavity in dermis or subcutaneous layer; tensely elevating skin. -Examples: Sebaceous cyst, wen
primary skin lesion bulla
-Larger than 1CM diameter; Usually single chambered unilocular -Superficial in the epidermis, thin walled and ruptures easily. -Examples friction blister, pemphigus, burns, contact dermatitis
primary skin lesion tumor
-Larger than a few centimeters in diameter, firm or soft, deeper into the dermis. Maybe benign or malignant -Examples: lipoma, hemangioma
primary skin lesions: patch
-Macular type lesion that is greater than 1 cm in diameter. -Example vitiligo; Mongolian spot, cafe-au-lait spot and measles rash
What is auscultation?
is Listening with a Stethoscope such as the heart, lungs, blood vessels and abdomen. -Blocks out noise -Diaphragm: High (Lung, heart, bowel) -Bell: Low (Heart murmurs or extra heart sounds)
When assessing the force, or strength, of a pulse, what should the nurse recall about the pulse?
is a reflection of the hearts stroke volume
what is inspection
occurs when we first see the client then thru each body system that happens during the "general survey" -using sense of sight to find symmetry and other unusual findings
secondary skin lesions crust
-The thickened, dried-out exudate left when vesicles/pustules burst or dry up. -Color can be red-brown, honey, or yellow, depending on the fluid's ingredients (blood, serum, pus). Examples: impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasion.
primary skin lesion nodule
-solid, elevated, hard/soft lesion more than 1 cm in diameter - deeper into the dermis then a Papule -Examples: xanthoma, fibroma, intradermal nevus
primary skin lesion plaque
-wider than 1cm, flat top surface -example psoriasis and lichen planus
What kind of data do we collect during the general survey?
Objective data (it is what we observe about the patient)
When using the various instruments to assess an older persons ADLs, what should the nurse keep in mind as a disadvantage of these instruments?
self or proxy reporting of functional activities
Which of these statements is true regarding the use of standard precautions in the health care setting?
standard precautions are intended for the use with all patients, regardless of their risk or presumed infection status
What is acute pain?
sudden onset, usually subsides once treated - aka transient pain - has short duration (generally does not last more than 6 months) - related to injury or illness
A nurse is assessing a client who has a score of 6 on the Glasgow coma scale. The nurse should expect which of the following outcomes based on this score?
the client needs total nursing care
While performing the physical examination, the nurse shares information and briefly teaches the patient. Why does the nurse do this?
to build rapport and increase the patients confidence in the examiner
What is the purpose of a general survey?
to obtain baseline data about patients
Primary Skin Lesions: Macule
-Solely a color change, flat and circumscribed, of less than 1 cm. -Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.
primary skin lesions: papule
-Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) - Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca).
primary skin lesion wheal
-Superficial, raised, transient, and erythematous -Slightly irregular shaped from edema (fluid held diffusely in the tissue). -examples: mosquito bite, allergic reaction, Dermographism
secondary skin lesions keloid
-hypertrophic scar, elevated, invasive beyond the site of injury -looks smooth, rubbery, claw like
secondary skin lesion fissure
-linear crack, moist or dry -example athlete's foot, cheilosis (cracks at corner of mouth)
what is the nutritional assessment used and what is it used for?
-mini nutritional assessment is a tool used for elderly people who are malnourished or at risk for malnutrition. The questions that are mainly asked are: 1. food intake declined due to loss of appetite, digestive problems, chewing/swallowing problem 2. weight loss 3. mobility 4. suffered from psychological stress/acute disease 5. neuropsychological problems 6. BMI index
what are the stages of pressure ulcers
-stage 1 nonblanchable erythema: intact skin and appears red but unbroken -stage 2 partial thickness skin loss: erosion with loss of epidermis & dermis, looks shallow like a open blister with a red-pink wound bed -stage 3 full thickness skin loss: extends to the subQ tissue. May see subQ fat but NOT muscle, bone or tendons -stage 4 full thickness skin/tissue loss: involves ALL skin layers that exposes the muscle, tendon/bone, and slough (stringy matter attached to wound bed) and eschar (black necrotic tissue) -deep tissue pressure injury (DTPI): is localized, nonblanchable color change to deep red, maroon or purple in intact/nonintact skin, epidermis may separate revealing the dark wound -the braden scale is used to evaluate the potential skin breakdown to prevent pressure ulcers developing
what is the functional assessment performed on older adults
-the Morse fall scale is used to assess a patients likelihood of falling. Items that are asked are: 2nd diagnosis, ambulatory aid, IV/heparin lock, gait/transferring and mental status -also asked about ADL's and IADL's to determine the level of assistance needed and level of independence. The katz-adl tool is used for this
Therapeutic communication
-the purposeful use of communication to build and maintain helping relationships with the client, families, and significant others -client centered: not social or reciprocal -purposeful, planned, and goal-directed
Primary skin lesion Urticaria (hives)
-wheals coalesce to form extensive reaction, intensely pruritic (itchy)
What's the normal range for pulse?
60-100 bpm (adult)
What's the normal range for Oxygen Saturation?
95-100%
What's the normal range for temp?
96.8F-100.4F
When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take while performing a physical examination?
Hands are washed before and after every physical patient encounter
what are the normal and abnormal for skin
NORMAL: -pigmentation: freckles, nevus (mole), birthmarks -temp: warm with equal temperature bilaterally, hypo/hyperthermia -moisture: dry, perspiration (sweating that happens in increased metabolic rates like working out) -texture: smooth and firm - thickness: uniformly thin & callus (excessive pressure on skin) - edema: no pitting -mobility and turgor: easily immediate return (less than a sec) -vascularity & bruising: easy bruising (trauma) -lesions: flat and small ABNORMAL: -moisture: dehydration mucous membranes that look dry -texture: HYPERthyroidism is the skin is smooth, soft and velvety feeling HYPOthyroidism is the skin feels rough, dry and flaky -mobility: poor turgor that can indicate dehydration or extreme weight loss
what are the normal and abnormal of the nail
NORMAL: -shape & contour: curved/flat, smooth/no edges, rounded/clean, firm no base -consistency: smooth nail surface, uniform nail thickness and nail adheres firmly to nail bed -color: pink nail beds, capillary refill (1-2 sec) ABNORMAL: -shape & contour: spoon nails/clubbed, jagged nails, dirty, paronychia -consistency: pits, transfer grooves, nails are thick, rigid and spongy -color: cyanosis/pallor, splinter hemorrhages, brown streaks on lighter skin
A nurse is performing a monofilament sensory assessment of a client who has diabetes mellitus. When performing this assessment, for which of the following complications is the nurse monitoring?
Neuropathy
During an assessment of an 80 year- old patient, the nurse notices the following: an inability to identifies a slower and more deliberate gait and a slightly impaired tactile sensation. All other neurologic findings are normal. How should the nurse interpret these findings?
Normal changes attributable to aging
What's the normal range for BP?
Normal: <120/<80 Hypotension: 90/60 (or lower) Elevated: 120-129/<80 HTN (stage 1): 130-139/80-89 HTN (stage 2): 140 or greater/ 90 or greater Hypertensive crisis: >180/>120
What are the different pain scales?
Numeric scale (0-10) 0= no pain at all 10= worst pain imaginable - subjective Faces scale (for children and non-english speaking patients) - subjective FLACC (Face, Legs, Activity, Cry, Consolability) - Used for infants and people who can't communicate/express pain - Objective PAINAD (Pain Assessment in Advanced Dementia) - Objective
What is chronic pain?
Pain continues for 6 months or longer - aka persistent pain - recurring pain - 2 types: malignant(cancer) and nonmalignant(other) nonmalignant examples: arthritis, peripheral neuropathy, etc.
When evaluating the temperature of older adults, the nurse should remember which aspect about an older adults body temperature?
The body temperature of the older adult is lower than that of a younger adult
What technique should the nurse use to accurately assess a rectal temperature in an adult?
use a lubricated blunt tip thermometer
Objective data
what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination
Subjective data
what they person says about himself or herself
The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
"Do you perform testicular self-examinations?"
What is the general survey?
A study/assessment of the whole person
what are some characteristics of cancerous skin lesions
ABNORMAL: know the ABCDE mnemonic: -Asymmetry of a pigmented lesion -Border irregularity -Color variation of areas of black/dark black, gray, blue (cyanosis- no O2 in the skin) , red (erythema- inflammation), white (pallor- anemia or circulatory probs) , pink, or yellow (juandice- increased lvls of bilirubin) -Diameter that is greater than 6 mm -Elevation/evolution of the mole (changes overtime) such as itching, burning, bleeding in a mole that raises suspension of malignant melanoma NORMAL: -pigmentation: freckles, nevus (mole), birthmarks -temp: warm, hypo/hyperthermia -moisture: dry, perspiration (sweating that happens in increased metabolic rates like working out) -texture: smooth and firm - thickness: uniformly thin & callus (excessive pressure on skin) - edema: no pitting -mobility and turgor: easily immediate return (less than a sec) -vascularity & bruising: easy bruising (trauma) -lesions: flat and small
A student is late for his appointment and has rushed across campus to the health clinic. How should the nurse proceed?
Allow 5 minutes for him to relax and rest before checking his vital signs
A nurse is assessing a clients cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve |||?
Checking the pupillary response to light
what are the normal and abnormal finding of the hair
NORMAL: -color: varies from blonde to black and gray of hair can begin as early as 30 -texture: can be fine or thick, can look straight, curly, or kinky but overall shiny -lesions: seborrhea (dandruff) ABNORMAL: -color: has no abnormal findings -texture: is dull, coarse or brittle scalp hair -lesions: lice (oval and adhere to hair shaft which causes intense itching
A nurse in an acute care mental health facility is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurses assessment priority?
Suicide risk
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
basal cell carcinoma has a low incidence of metastasis
The nurse should measure rectal temperatures in which of these patients?
comatose adult
When examining an older adult, the nurse should use which technique?
arrange the sequence of the examination to allow as few position changes as possible
The nurse is performing a nutritional assessment on a 15 year old girl who tells the nurse that she is "so fat." Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. What is an appropriate response by the nurse?
"Tell me more about that. How much do you think you should weigh?"
A patients blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" Which is the best reply by the nurse?
"The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts."
secondary skin lesion lichenification
-Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)
primary skin lesion pustule
-Pus-filled vesicle or bulla. -Example: acne, impetigo
secondary skin lesion atrophic scar
-Resulting skin level is depressed with loss of tissue, a thinning of the epidermis -example: striae (stretch marks)
secondary skin lesions erosion
-Scooped out but shallow depression, Superficial lesion, epidermis lost -moist but no bleeding; heals without scar because erosion does not extend into dermis.
secondary skin lesion excoriation
-Self-inflicted abrasion, superficial, sometimes crusted, scratches from intense inching. -Examples: insect bite, scabies, dermatitis, Varicella
Describe exams that assess cerebellar and sensory function, including safety measures.
Cerebellar Function Exams and Safety Measures Gait Exam: - Person walks 10 to 20 feet, turns, and returns to starting point. - Step length is about 15 inches from heel to heel. - Normal findings - smooth, rhythmic, and effortless - Abnormal findings - Stiff immobile posture, staggering, unequal rhythm of steps, uncoordinated gait Romberg Test: - Patient stands with feet together and arms at sides, eyes closed, and hold for about 20 secs. - Ask patient to perform a shallow knee bend or hop in place to demonstrate normal muscle strength - Normal findings: patient maintains posture and balance with slight swaying - Positive Romberg sign is loss of balance increased by closing of the eyes Sensory Function Exams and Safety Measures Superficial Pain - Break tongue blade so that there is a sharp end and dull end. Apply the sharp end on patients' body and ask person if it is a "sharp" or "dull" sensation. - Abnormal findings - Hypoalgesia (Decreased pain sensation) Analgesia (Absent pain sensation) Hyperalgesia (Increased pain sensation) Light Touch - Stretch a cotton ball and brush over patient's skin in a variety of places and have patient respond when they feel the touch. - Abnormal findings - Hypoesthesia (Decreased touch sensation) Anesthesia (Absent touch sensation) Hyperesthesia (Increased touch sensation) Vibration - Strike a low-pitched tuning fork on heel on heel of your hand and hold the base on a bony surface on fingers and great toe. - Ask patient to indicate when the vibration starts and stops. - Normal findings - response is vibration or buzzing sensation on distal areas - Abnormal findings - Unable to feel vibration, states there is no vibration
Appropriate procedure and nursing considerations for assessing BP
Considerations: - make sure their legs aren't crossed - Use the right cuff size - After activity, let patient rest for at least 5 minutes before measuring BP - HTN is diagnosed with 2 elevated BP measures on 2 separate occasions - Don't measure BP on same side of body as a mastectomy w/ lymph node dissection or in an extremity w/ edema, trauma, peripheral IV catheter, arteriovenous fistula
Identify expected and unexpected findings associated with the cranial nerve tests.
Expected Findings: CN (2) Optic Nerve - Test visual activity and visual fields CN (3,4,6) Oculomotor, Trochlear, & Abducens - Palpebral fissures are usually equal in width - Pupils should be equal and reactive CN (5) Trigeminal Nerve - Muscles should feel equally strong on both sides - Test patients touch sensation by using the light touch test CN (7) Facial Nerve - Facial symmetry as the patient responds to requests CN (8) Acoustic Nerve - Test patient's ability to hear normal conversation and whisper CN (9 & 10) Glossopharyngeal and Vagus - Depress on patient's tongue and say "ahhh" -> uvula and soft palate should rise CN (11) Spinal Accessory Nerve - Ask patient to turn their head against your resistance or have patient shrug their shoulders against your resistance CN (12) Hypoglossal Nerve Patient should stick their tongue out and tongue should line up midline Unexpected Findings: CN (2) Optic Nerve - Visual field loss - Papilledema -> optic atrophy CN (3,4,6) Oculomotor, Trochlear, & Abducens - Drooping of face with Myasthenia Gravis - Unequal size or constricted pupils - No response to light - Deviated gaze or limited movement CN (5) Trigeminal Nerve - Decreased strength on one or both sides - Pain with clenching of the teeth - Decreased or unequal sensation CN (7) Facial Nerve - Muscle weakness shows by drooping of one side of the face: eyelid sagging CN (9 & 10) Glossopharyngeal and Vagus - Absence or asymmetry of soft palate due to a stoke CN (11) Spinal Accessory Nerve - Atrophy of neck muscles - Muscle weakness or paralysis CN (12) Hypoglossal Nerve - Fasciculations - Tongue deviates to side
Identify categories of the Glasgow Coma Scale.
Glasgow Coma Scale - Three categories: Eye opening, Motor Response, and Verbal response - Each area is rated separately, and number is given for patient's best response - A fully alert, normal person has a score of 15! - A score of 7 or less reflects coma!
What does the review of systems provide the nurse?
Information regarding health promotion practices
Differentiate terms involved in level of consciousness.
Level of Consciousness - Assess patient's orientation by asking person, place, and time. - Patient is alert when patient has eyes open when approached and is orientated when person can follow verbal commands appropriately. - If patient isn't fully orientated then increase amount of stimulus like name called, light touch, vigorous shake, and pain applied. Alert: awake, orientated, and fully aware of external and internal stimuli - Lethargic: Not fully alert, drift off to sleep when not stimulated, and looks drowsy. - Obtunded: Sleeps most of time, acts confused, and speech may be mumble. - Stupor: Spontaneously unconscious and only responds to vigorous shake and pain. - Coma: Completely unconscious and nonresponsive to anything. - Recent Memory: Like assessing recent memory in context of 24-hour diet recall. - Remote memory: Assessing past events in patients life. Motor Function - Check the voluntary movement of each extremity by giving specific commands to patient. - Ask patient to lift the eyebrows. - Check upper arm strength by checking hand grasps. - Check lower extremities by asking person to do straight leg raises. Papillary Response - Note size, shape, and symmetry of both pupils. - Shine light into each pupil and note the direct light reflex Vital signs - Measure temperature, pulse, respiration, and blood pressure.
Appropriate procedure and nursing considerations for assessing respirations
Pretend you're still counting the pulse. Count respirations for 30 sec and multiply by 2 If respirations are abnormal count for 1 minute
Appropriate procedure and nursing considerations for assessing temp
Procedure: - Routes: oral, tympanic, temporal, axillary, rectal Considerations: - Different parts of body have different temperatures - Rectal is most accurate but should only be used when other routes are not practical/available
Appropriate procedure and nursing considerations for assessing pulse
Procedure: we typically check the radial pulse (count for 30 sec and multiply by 2) If abnormal, count for 1 minute
What are the normal variations of respirations?
Resp. rate is usually faster in children and infants
What's the normal range for BMI?
Underweight: <18.5kg/m Healthy/normal: 18.5-24.9kg/m Overweight: 25-29.9kg/m Obesity: 30kg/m or greater
what is palpation
applies to areas to assess and feel the texture, temp, moisture, organ location & size, swelling, vibrations, and tender areas (PALPATE LAST) -Fingertips: is the light sense of touch for Surface characteristics, palpating, presence of lumps, skin texture -Grasping action of fingers: deep sense of touch is used for abdominal contents and detect the position/size of an organ -Dorsum/back of hands: for Temperature bc skin is thinner