Health Assessment And Physical Exam (Basics Test 2 Charity)

Front 1

What type of data is the physical exam?

Back 1

Objective data

Front 2

What is the student nurse's responsibility regarding the physical exam?

Back 2

Recognizing the normal from the abnormal

Front 3

How does a student nurse recognize the normal from the abnormal?

Back 3

-use proper technique
-identify changes and trends
-validate & analyze data
-discuss clinical significance of data
-communicate significant data
-document w/i normal limits (WNL)

Front 4

What type of data is the physical exam?

Back 4

Objective data

Front 5

What is the student nurse's responsibility regarding the physical exam?

Back 5

Recognizing the normal from the abnormal

Front 6

How does a student nurse recognize the normal from the abnormal?

Back 6

-use proper technique
-identify changes and trends
-validate & analyze data
-discuss clinical significance of data
-communicate significant data
-document w/i normal limits (WNL)

Front 7

a subjective statement made by a patient describing the most significant or serious symptoms or sings of illness or dysfunction that caused him or her to seek health care

Back 7

Chief Complaint

Front 8

Systematic orderly process by which the nurse collects objective data about the client's body, mind and spirit. It is time oriented (collects data about the present time)

Back 8

Physical Examination

Front 9

Objective data

Back 9

data that is observed or measured

Front 10

Low Fowler's Position

Back 10

Sitting Position

Front 11

Timeframe for the physical examination

Back 11

15-20 minutes

Front 12

You should always allow a client an opportunity to _____________ before beginning a physical exam.

Back 12

Urinate

Front 13

Three important aspects of the physical exam

Back 13

1. provide privacy
2. close the door and the drapes
3. positioning

Front 14

Visual examination; to observe, to look, to notice, to smell. The nurse notices or observes shape, size, color, position, movement, symmetry, equality, etc.

Back 14

Inspection

Front 15

DEF.
do the patient's words match his or her behavior

Back 15

congruence

Front 16

DEF.
appearance, do both sides look the same

Back 16

symmetry

Front 17

DEF.
term used when you can actually measure the amount of something and compare

Back 17

equality

Front 18

Using the sense of touch; to feel, to stroke the surface of an are to detect its characteristics such as temperature, vibration; turgor; texture; masses, etc.

Back 18

Palpitation

Front 19

What part of the fingers should be used in palpitation? Why?

Back 19

the pads of the fingers. There is a high concentration of sensory nerve endings at the pads which are most sensitive to tactile discrimination.

Front 20

What type of palpitation is 1-2 cm with the hand parallel to the client's skin surface, maintaing skin contact while moving in a circle

Back 20

Light or superficial palpitation

Front 21

Involves striking the body to elicit sounds that indicate whether tissue is solid, fluid-filled or air-filled. (Not practices in Basics)

Back 21

Percussion

Front 22

Listening to sounds produced int he body; aided by the use of a stethoscope which focuses and amplifies sound

Back 22

Auscultation

Front 23

With a stethoscope, high-pitched sounds are heard best with the

Back 23

Diaphragm

Front 24

With a stethoscope, low-pitched sounds are heard best with the

Back 24

Bell

Front 25

What is used for difficult to hear pulses and to hear fetal heart tones (it augments sound)

Back 25

Doppler

Front 26

What is AAOx3?

Back 26

Documentation for Awake, Alert, Oriented x3 (person, place, time)

Front 27

List of Initial Observations as it pertains to the physical exam:

Back 27

-Position of Patient
-Client Activity or Interaction
-Response to stimuli
-Signs of Distress

Front 28

Define awake as it pertains to response to stimuli:

Back 28

Are the patient's eyes open

Front 29

5 levels of alertness as it pertains to response to stimuli:

Back 29

-spontaneously respond to the nurse's entry
-Verbal (did the nurse have to call his name)
-Tactile (did the nurse have to touch the patient)
Painful stimuli (pinch b/t the fingers)
-No response to stimuli

Front 30

In reference to orientation, how do you test for person, place and time?

Back 30

-What is your full name?
-What city (or state) are we in?
-What time of day is it? What month? Year?

Front 31

List of signs of distress:

Back 31

-Airway/Breathing
-Circulation
-CHANGE in level of consciousness (LOC)
-Complaint

Front 32

DEF
states that there is difficulty in breathing; SOB; may use accessory muscles; works hard to breathe

Back 32

Dyspnea

Front 33

production of secretions in coughing

Back 33

sputum

Front 34

bloody sputum

Back 34

hemoptysis

Front 35

tissue perfusion (ashen gray)

Back 35

ischemia

Front 36

Wheezing or stridor (crowing)

Back 36

restrictive sounds as it pertains to airway noises

Front 37

blue; blue-gray

Back 37

cyanotic; cyanosis

Front 38

patchy areas of blue

Back 38

mottled

Front 39

pale

Back 39

pallor

Front 40

reddish blue

Back 40

flushed

Front 41

skin moist with perspiration

Back 41

diaphoretic

Front 42

any medical equipment or devices in use for the patient

Back 42

Adjunct Equipment

Front 43

Very thin

Back 43

emaciated

Front 44

rigid small slow steps, then fast forward leaning small steps; difficult to stop (may be seen with Parkinson's)

Back 44

Propulsive gait

Front 45

axillae

Back 45

armpits

Front 46

mouth odor possibly from poor oral hygiene

Back 46

halitosis

Front 47

cavities

Back 47

dental caries

Front 48

difficulty with speech or difficulty understanding the spoken word

Back 48

dysphasia

Front 49

Bluish color or hypoxia in the nail beds, lips, mouth or buccal mucosa or mucous membranes (in dark skinned: look at conjunctiva, palms, soles of feet)

Back 49

cyanotic

Front 50

loss of color due to inadequate circulating blood or hemoglobin (anemia); or decrease oxygenation of the hemoglobin; or general poor health status (in dark skin may appear ashen gray) assess in conjunctive, lips and palms

Back 50

pallor

Front 51

Cyanosis in a light skin (pink) person looks ... In a brown person

Back 51

-looks dusky blue
-looks ashen gray esp. on lips and tongue

Front 52

yellow orange skin, sclera, mucous membranes (mm); on dark skinned person will be the hard palate; caused by excess bilirubin from liver or hemolytic diseases

Back 52

jaundice

Front 53

red; increased blood flow; inflammation; rashes

Back 53

erythema

Front 54

brown age spots due to sun exposure

Back 54

senile lentigo

Front 55

perspiration

Back 55

diaphoresis

Front 56

The skin is considered this when released is quickly snaps back to pretested position

Back 56

supple

Front 57

bruising

Back 57

ecchymosis

Front 58

pinpoint red-purple spots caused by small hemorrhages; may indicate bleeding disorder, liver disease, drug reaction, infections

Back 58

petechiae

Front 59

the abnormal presence of fluid int he body

Back 59

Edema (or effusion)

Front 60

edema around the eyes

Back 60

periorbital edema

Front 61

edema in brain

Back 61

cerebral edema

Front 62

edema in pericardial sac

Back 62

pericardial effusion

Front 63

edema in intrapleural space

Back 63

pleural effusion

Front 64

edema in abdominal cavity

Back 64

ascites

Front 65

Generalized edema (all over)

Back 65

anasarca

Front 66

When an indention remains with edema

Back 66

pitting edema

Front 67

Edema is affected by gravity and therefore is commonly seed in...

Back 67

dependent areas (legs, sacrum, scrotum)

Front 68

an abnormal (pathological) area of the skin

Back 68

lesion

Front 69

A,B,C,D as it pertains to lesions

Back 69

A-asymmetrical or uneven shape
B-border irregularity
C-change in color; odd color; elevated
D-diameter>6mm (pencil eraser)

Front 70

small raised red papules

Back 70

cherry angiomas

Front 71

partial or complete hair loss

Back 71

alopecia

Front 72

nearsightedness

Back 72

nyopia

Front 73

farsightedness

Back 73

hyperopia

Front 74

lens of eye is unable to change shape to accommodate close vision; has difficulty reading small print; starts around 45 yrs

Back 74

presbyopia

Front 75

When an indention remains with edema

Back 75

pitting edema

Front 76

Edema is affected by gravity and therefore is commonly seed in...

Back 76

dependent areas (legs, sacrum, scrotum)

Front 77

drooping of the eye lid over the pupil

Back 77

ptosis

Front 78

an abnormal (pathological) area of the skin

Back 78

lesion

Front 79

A,B,C,D as it pertains to lesions

Back 79

A-asymmetrical or uneven shape
B-border irregularity
C-change in color; odd color; elevated
D-diameter>6mm (pencil eraser)

Front 80

small raised red papules

Back 80

cherry angiomas

Front 81

partial or complete hair loss

Back 81

alopecia

Front 82

nearsightedness

Back 82

myopia

Front 83

farsightedness

Back 83

hyperopia

Front 84

lens of eye is unable to change shape to accommodate close vision; has difficulty reading small print; starts around 45 yrs

Back 84

presbyopia

Front 85

drooping of the eye lid over the pupil

Back 85

ptosis

Front 86

bilateral gray ring outlining the iris; made of lipid deposits; benign

Back 86

Arcus senilis

Front 87

PERRLA

Back 87

-Pupils Equal
-Round
-React to Light
-Accommodation (consensual response)

Front 88

Dilation of pupils

Back 88

mydriasis (remember both have D's)

Front 89

constriction of pupils

Back 89

miosis (remember constriction and miosis both have o's)

Front 90

wax in the external ear canals

Back 90

cerumen

Front 91

hearing deficit

Back 91

presbycusis

Front 92

ringing in ears

Back 92

tinnitus

Front 93

red large gums

Back 93

Gingival hyperplasia

Front 94

no teeth or number of teeth missing

Back 94

Edentulous

Front 95

cavities

Back 95

caries

Front 96

Unequal sounds or an incorrect sound heard in an airway location

Back 96

adventitious sounds

Front 97

miosis

Back 97

pupils constrict (miotic effect)

Front 98

mydriasis

Back 98

pupils dilate (midriatic effect)

Front 99

First heart sound is created by the...

Back 99

closure of the mitral and tricuspid valves (systole)

Front 100

Second heart sound is created by the...

Back 100

closure of the aortic and pulmonic valves (diastole)