Nursing 1St Semester- Assessment

Front 1

How long does a routine assessment take and when is it done?

Back 1

10-15 minutes, at beginning of each shift more frequently when a client's health status changes (sometimes done less often in nursing homes and home care setting)

Front 2

When does a nurse do a comprehensive assessment?

Back 2

When a patient is admitted to a health care facility

Front 3

5 basic assessment techniques

Back 3

inspection
palpation
percussion
auscultation
olfaction

Front 4

Inspection requires what 2 things

Back 4

good lighting and full exposure of selected body parts

Front 5

What must we look for when we are inspecting?

Back 5

size, shape, color, symmetry, position, presence of abnormalities. When possible, inspect each area compared with same area on opposite side of body

Front 6

Verify and clarify all abnormalities with _____ client data.

Back 6

Subjective
In other words, ask client for further information about each abnormality or change.

Front 7

What does palpation detect?

Back 7

resistance, resilience, roughness, texture, temperature, mobility. Often used with or after visual inspection.

Front 8

The _____ of the hand is sensitive to temperature variations (palpation)

Back 8

dorsal side (back of hand)

Front 9

The ___ of the hand is especially sensitive to vibration

Back 9

palm

Front 10

The ______ of the _____ detect subtle changes in texture, shape, size, consistency, and pulsation of body parts.

Back 10

pads of fingertips

Front 11

The nurse measures ____, ____, and _____ by lightly grasping the body part with the fingertips.

Back 11

position, consistency, and turgor

Front 12

____ _____ during palpation impairs the ability to palpate correctly.

Back 12

Muscle tension

So help the client relax by asking him/her to take slow, deep breaths.

Front 13

True or false: Palpate tender areas first.

Back 13

False, palpate tender areas last.

Front 14

Light palpation ____ deep palpation

Back 14

precedes

Front 15

How often should breast self-examinations should be done ?

Back 15

once per month

Front 16

For women who menstruate, the best time to do BSE is ___ or ____ days after a period endes, when the breasts are least likely to be tendon or swollen.

Back 16

2 or 3 days
(Women who no longer menstruate should just do BSE on same day every month, such as the first day.)

Front 17

What sort of unusual changes should women look for in their skin during a BSE?

Back 17

discharge from nipples, puckering, dimpling, or scaling of skin

Front 18

The second part of the BSE should be done ___ ___ ____.

Back 18

In the shower. (Gliding fingers over soapy skin makes it easier to notice the texture underneath.)

Front 19

For the final steps of the BSE, the position is ____.

Back 19

lying down. This position flattens the breast and makes it easier to examine.

Front 20

During BSE, pay special attention to the area around the ____.

Back 20

armpit (and between breast & armpit)

Front 21

During BSE move from the ____ edge and press the flat part of your fingers around in small ____, moving slowly around the breast gradually working toward the nipple.

Back 21

outer, circles

Front 22

Men ____ years of age or older should perform a genital self-examination ______.

Back 22

15 years of age, monthly

Front 23

When should the genital exam be done?

Back 23

After a warm bath/shower when scrotal sac is relaxed

Front 24

In a penile examination, look for ....

Back 24

bumps, sores, blisters, bympy warts, discharge from penis

Front 25

Where should a man do a penile/testicular examination?

Back 25

In front of a mirror.

Front 26

What should he look for in a testicular examination?

Back 26

feel for lumps, thickening, or a change in consistency (hardening) . Do this by gently rolling testicle with thumb on top. Feel for small, pea-sized lumps on front and side of testicle, they are usually painless but are ABNORMAL.

Front 27

For light palpation, apply pressure slowly, gently and deliberately, depressing about ____ .

Back 27

1/2 inch or 1 cm

Front 28

Deeper palpation can be used to examine condition of organs. Depress the area being examined about _____.

Back 28

1 inch or 2 cm

Front 29

_____ palpation involves one hand placed over the other while applying pressure

Back 29

bimanual (the upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses.

Front 30

Seek assistance from your instructor before attempting ____ palpation.

Back 30

deep

Front 31

______ involves tapping the body with the fingertips to evaluate size, borders, and consistency of body organs and to discover fluid in body cavities. It identifies location, size, and density of underlying structures.

Back 31

Percussion

Front 32

To percuss, you strike the body's surface with a finger to create a _____. The character of sounds depends on the ____ of underlying tissues.

Back 32

vibration, density

Front 33

T or F: Percussion is easy.

Back 33

False. It requires practice and skill and is typically used by advanced practice nurses (APNs)

Front 34

4 characteristics of sound hear through auscultation

Back 34

frequency, loudness, quality, duration

Front 35

True or False: It is essential to place the stethoscope directly on client's skin because clothing obscures and changes sound.

Back 35

True

Front 36

______ uses the sense of smell to detect abnormalities that go unrecognized by other means.

Back 36

Olfaction

Front 37

The smell of ammonia in urine could indicate..

Back 37

UTI

Front 38

hyperhidrosis

Back 38

excessive perspiration

Front 39

bromhidrosis

Back 39

foul-smelling perspiration

Front 40

halitosis

Back 40

foul smelling breath

Front 41

the smell of a sweet, heavy,thick odor from a draining wound could indicate...

Back 41

pseudomonas (bacterial) infection

Front 42

the smell of stale urine on the skin could indicate...

Back 42

uremic acidosis

Front 43

the smell of sweet, fruity ketones in the oral cavity could indicate...

Back 43

diabetic acidosis

Front 44

Foul-smelling stool in infants could indicate...

Back 44

malabsorption syndrome

Front 45

A musty odor coming from a casted body part could indicate...

Back 45

infection inside cast

Front 46

A fetid, sweet odor from a tracheostomy or mucous secretions could indicate...

Back 46

infection of bronchial tree (pseudomonas bacteria)

Front 47

The smell of feces from a wound site could indicate...

Back 47

wound abscess

Front 48

The smell of alcohol from the oral cavity could indicate

Back 48

Hmm I wonder...

Front 49

The smell of feces in vomit (vomitus) could indicate...

Back 49

bowel obstruction

Front 50

the smell of feces in the rectal area could indicate...

Back 50

fecal incontinence

Front 51

Make sure you have a ____ ____ ____ ____ ____ ____ in room during assessment of genitalia

Back 51

third person of client's same gender

Front 52

For assessing ___________, focus on growth and development, sensory screening, dental examination, and behavioral assessment.

Back 52

children

Front 53

Call children by their ____ name and address adults/parents as "Mr./Mrs. Jones" etc.

Back 53

first

Front 54

True or false: Older children and adolescents respond better when treated as children.

Back 54

False, they are more responsive when treaetd as adults and individuals

Front 55

The adolescent has a right to _____.

Back 55

confidentiality

Front 56

For older adults, take advantage of natural opportunities for assessment such as ______, _____, and _____.

Back 56

bathing, grooming, mealtimes

Front 57

_______ an examination with older adults to keep position changes to a minimum. Be efficient throughout the examination to limit client movement.

Back 57

Sequence (throughly think through the order in which you will examine the individual)

Front 58

Make sure that an examination of an older adult includes a review of ____ _____.

Back 58

mental status

Front 59

Results have found that mammography screening for women age ___ years and older at least every ___ years was still favored as a method of breast cancer detection.

Back 59

age 40 and older, every 2 years

Front 60

True or false: Perform painful or intrusive procedures near the beginning of the exam.

Back 60

False: Near the end of the exam

Front 61

Follow the sequence of inspection, palpation, and auscultation thoruhgout the body except for in the _____ assessment.

Back 61

abdominal assessment in which we inspect, auscultate, and then palpate. (Palpation can alter or disrupt the auscultation.)

Front 62

True or False: In long term health care setting, arm bands (for identifying the patient) are not used.

Back 62

True. Pictures are available for identification

Front 63

Clients with difficulty hearing or an altered ____ may answer to a name other than their own.

Back 63

LOC

Front 64

Always wear gloves if there are _____, _____, or breaks in the skin. In some situations, you may need to wear a gown.

Back 64

lesions, wounds

Front 65

Record quick notes to facilitate____ documentation

Back 65

accurate

Front 66

Which culture/ethnic group is often:
highly tactile, very modest (men and women) may ask for health care provider of same gender, women may refuse to be examined by a male health care provider

Back 66

Hispanic

Front 67

Which culture/ethnic group is should we: avoid touching (patting head is strictly taboo), and touching during an argument equals loss of control (shame) and public display of affection toward members of same gender is ok just not opposite gender

Back 67

Asians/Pacific Islanders

Front 68

Which culture/ethnic group often:
does not like to be touched without permission, may exercise level of distrust or caution initially in health care provider

Back 68

African-Americans

Front 69

Which culture/ethnic group should we shake hands with lightly, and they don't like to be touched without permission. Nonverbal communication is very important.

Back 69

Native Americans

Front 70

Immobility, moisture from incontinence, inadequate nutrition, and circulatory alterations may cause/ influence a diagnosis of ____

Back 70

Impaired skin integrity or risk for impaired skin integrity

Front 71

Hypoventilation or hyperventilation along with influencing factors such as pain, anxiety, and decreased muscle strength/energy may indicate a diagnosis of ____

Back 71

ineffective breathing pattern

Front 72

______ pain is one of the most common symptoms found in hospitalized clients.

Back 72

abdominal

Front 73

Ineffective tissue perfusion involves a _____ deficit in blood supply to the _______ and is appropriate when finding reveal alteration in arterial or venous circulation.

Back 73

chronic, extremeties

Front 74

Disturbed thought process would be a nursing diagnosis if a client lacks ______ to time, person, and/or event or demonstrates an abnormality in any of the six components of the mental health examination.

Back 74

orientation

Front 75

The _____ _____ begins a review of the client's primary health problems and includes vital signs, height and weight general behavior, and appearance. It provides info about characteristics of an illness, a client's hygiene, skin and body image, emotional state, recent changes in weight, and developmental status.

Back 75

general survey

Front 76

If client has any acute signs of distress during a general survey, such as ____, ______, and ______, postpone general survey until later and focus immediately on body system affected.

Back 76

difficulty breathing, pain, anxiety

Front 77

When there is a language barrier, it is best to have an interpreter of the same _____ who is older and more mature. Translate ____ if possible.

Back 77

gender,
verbatim

Front 78

1 liter of water weighs _____ kg or ____ lbs.

Back 78

1 kg or 2.2 pounds

Front 79

Weight of ___ to ___ % above standard indicates excess body fat. However, _____ _______ is one factor that must be ruled out.

Back 79

10 - 20%
fluid retention

Front 80

Repeated exposure to latex gloves may result in serious reactions like ____, itching, and _______.

Back 80

asthma, itching, anaphylaxis

Front 81

Measuring height and weight, oral intake, urinary output, vital signs and reporting a client's subjective signs and symptoms may be delegated EXCEPT the ____ set or when client is ______

Back 81

EXCEPT the INITIAL set or when client is UNSTABLE

Front 82

In the general survey, take vital signs unless routinely taken within past ____ hours

Back 82

3

Front 83

Behavior may reflect specific ____ abnormalities. ____ and LOC influence ability to cooperate.

Back 83

physical, Dementia

Front 84

Timing of recent medications, especially _____ ______ and ______ may cause client to be groggy or less responsive.

Back 84

pain medication and sedatives

Front 85

In appropriate response from client may be caused by language ______, deterioration of mental ____, preocupation with _____ or decreased ______ acuity.

Back 85

barrier
status
illness
hearing

Front 86

If a client knows his name, location, and situation, you can write " ________" in your documentation

Back 86

"Oriented x 3"

Front 87

_____ exists along a continuum that includes full responsiveness, inability to consciously initiate meaningful behaviors, and unresponsibeness to stimuli.

Back 87

LOC

Front 88

MMSE

Back 88

Mini-Mental State Examination, to be done when client has a questionable LOC. If drastic changes in mental status, notify physician.

Front 89

Evidence of abuse is often identified first by ____ _____ _____, because clients are often unable to tell family or friends.

Back 89

health care providers

Front 90

Signs of child sexual abuse

Back 90

blood on underclothing, pain in genital area, difficulty sitting or walking

Front 91

Main sign of abuse is injury or trauma that is _______ with reported _____

Back 91

inconsistent with reported cause

Front 92

______ interval between injury and time medical care was sought are signs indicative of older adult abuse or neglect.

Back 92

Prolonged

Front 93

___ injuries are left when an object with which a person is struch leaves an imprint

Back 93

Pattern

Front 94

_____ injuries such as bilateral bruises on upper arms suggest the person was held or shaken

Back 94

Parallel

Front 95

Melanoma is ___ times higher among whites than blacks.

Back 95

10 x

Front 96

______, (pinpoint red/purple spots on skin caused by small hemorrhages in skin layers) may indicate serious clotting disorder, drug reaction, or liver disease

Back 96

Petechiae

Front 97

Be alert for ____ cell carcinomas, such as an open sore that does not ____, shiny ______, a pink or reddish growth, or a scar-like area.

Back 97

Be alert for BASAL cell carcinomas, such as an open sore that does not HEAL, shiny NODULES, a pink or reddish growth, or a scar-like area.

Front 98

pneumonic rule for melanoma

Back 98

ABCD
Asymmetry of lesion
Borders; irregular
Color blue/black or varied
Diameter greater than 6mm

Front 99

What diameter is a cause of concern for possible malignant melanoma?

Back 99

> 6mm

Front 100

You can more easily identify abnormalities in the body where melanin production is ____. Look at color of face, oral mucosa, lips, conjunctivae, sclera, palms of hands, and nail beds.

Back 100

lowest

Front 101

What are some signs of impaired circulation?

Back 101

pallor, decreased temperature
Often caused by restraints, casts, bandages, etc.

Front 102

Changes in ____ may be the first indication of skin rashed in dark-skinned clients

Back 102

texture

Front 103

signs of xerosis

Back 103

dry, scaly skin

Front 104

A ____ __ pressure ulcer may cause warmth and erythema (redness) of an area.

Back 104

Stage 1

Front 105

With altered skin ____ it is essential to provide measures for prevention of pressure ulcers

Back 105

turgor

Front 106

Peripheral cyanosis results from low ___ ___ or local _________.

Back 106

cardiac ouput, vasoconstriction

Front 107

Signs of petechiae in dark skin individual

Back 107

unsually invisible except in oral mucosa, conjunctivae, eyelids and covering of eyeballs

Front 108

_____ of the skin is related to decreased perfusion (blood flow, anemia, shock) . How is it different for darker skinned individuals?

Back 108

pallor. Ashen-gray appearance in black skin.

Front 109

How do you assess erythema in a light skinned vs. a dark skinned person?

Back 109

Light: redness easily apparent
Dark: Difficult to assess, palpate for warmth/edema

Front 110

______ is relate to deposits of bilirubin in tissue and liver disease. In dark skinned individuals, it's reliably assessed in sclerae, hard palate, palms, and soles of feet. In light skinned individuals, it's a yellow staining in sclerae of eyes, skin, etc.

Back 110

jaundice

Front 111

How do we find ecchuymoses in dark skinned individuals?

Back 111

difficult to see except in mouth or conjunctivae

Front 112

Cyanosis is related to hopxia (late sign of decreased oxygen), heart/lung disease, cold environment. What changes will we see in light/dark skin individuals?

Back 112

Light: blue tinge especially in conjunctivae, nail beds, ear lobes, oral membranes, palms

Dark: ashen-gray lips, tongue

Front 113

Description of ________ helps to indicate whether infection is present or the wound is healing

Back 113

secretions

Front 114

Areas at risk for pressure ulcers

Back 114

sacrum, greater trochanter, heels, occipital area, clavicles

Front 115

Normal reactive hyperemia (redness) is a visible effect of localized vasodilation, the body's normal response to lack of blood flow to underlying tissue. Except for in the case of a stage 1 pressure ulcer, affected area will ____ with fingertip pressure.

Back 115

blanch.

Front 116

If pressure on skin & bony prominence is not relieved, tissue damage can occur in as little as ____ minutes.

Back 116

90 minutes due to tissue hypoxia.

Front 117

hemoptysis

Back 117

bloody sputum

Front 118

ischemia

Back 118

inadequate tissue perfusion resulting in an inadequate delivery of oxygen and nutrients to cells. Results in pain.

Front 119

occlusion

Back 119

blockage