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288 Cards in this Set

  • Front
  • Back

Which of the following is included in documenting a history source?


A) appearance dress hygiene


B) cognition and literacy level


C) document in a relationship of support system


D) reliability of information

Reliability of informant

A patient sees care for a debilitating headaches that causes excess absences from work on further exploration the nurse asked what makes the headaches worse with this question the nurse is seeking information about..

Aggravating factors

The CAGE test is a screening questionnaire that helps to identify

Excessive or uncontrollable drinking

An evaluation of past and present health state of each body system is called the

Review of systems in health history

When recording information for the review of systems the interviewer must document

The presence or absence of all symptoms under the system heading

Assessment of self esteem and self concept is part of a functional assessment areas covered under self esteem and self-concept are

Education financial status and value belief system

PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to

Pain perception

The nurse questions the reliability of the history provided by the patient one method to verify information within the context of the interview is to

Rephrase the same question later in the interview

When taking a health history from an adolescent the interview interviewer should

Interview the used alone with a parent in the waiting area

What information is included in greater detail when taking a health history on an infant

Nutritional data

Subjective sensation that the person feels from the disorder

Symptom

An objective abnormalities at you as the examiner could detect on physical examination or lab reports

Sign

PQRSTU stand for

provocative or palliative


quality or quantity


region or radiation


severity scale


timing


understanding patients perception

Biographical data, reason for seeking care, present health or history of present illness, past health, family history, review of systems, functional assessment are the 7 components of..

Health history

When taking the _______ you ask for names address phone number optional, age and birthdate, sex, marital status raised occupation source of history

Biographical data

Location, character or quality, quantity or severity, timing, setting, aggravating or leaving factors, associated factors, and patience perception are characteristics of

A symptom

Childhood illnesses, accidents or injuries, serious or chronic illness, hospitalizations, operations, obstetric history, immunizations, last examination date, allergies, current medications are components of

Past health history

Age and health or cause of death of blood relatives, health of close family members spouse children, family history of various conditions is included in taking

Family history

The __________ __ ________ is for evaluating the past and present health state of each body system, to double check in case significant data were omitted in present illness section, to evaluate health promotion practices, remember that this is subjective data part of history

Review of systems

__________ measures the person self-care ability in health and in absence of illness and includes assisted daily living independent living, nutrition, social relationships and resources ,coping ,home environment

Functional assessment

___________ areas are Self esteem self concept, activity / exercise, sleep rest, nutrition / elimination, interpersonal relationships / resources, coping and stress management, personal habits, alcohol, drugs, environment hazards, occupational health

Functional assessment areas

Questions you ask when taking their _________ ___ ______ how do you define else? How do you do your situation now? What are your concerns goals? What do you think will happen in the future? What do you expect from your healthcare providers?

Perception of health

Questions to include in ------ -- ------ for the older adult include questions about how ADLS is affected by aging process, past health back 5 years, health promotion and functional assessment on important

Perception of health

For assessment techniques in the clinical setting are

Inspection palpation percussion auscultation

Begins at the first moment you meet the patient use senses sight smell touch hearing always the first step in physical assessment of any body system systemic deliberate critical observations concentrated watching

Inspection

Use of touch determine textures size consistency and location a body parts.. types light and deep light detect surface characteristics helps patient come acclimated to being touched Deep is used for abdominal contents

Palpation

How to ------- ...Fingertips use for fine tactical discrimination..finger thumb opposition use for position shape consistency of an organ/mass


Dorsa of hands / fingers use for temp. Metacarpophalangeal joints or ulnar side of hand for vibration

Palpation

The f.i.c a questions are about

Spiritual resources questions to incorporate the person's spiritual values into health history f for faith i is for influence C is for community A is for address (any problems or issues)

The art of striking one object against another to create sound

Percussion

Technique of percussion: __________ hand and ____ finger placed firmly on area to be percussed; fingers seperated.. tip of ____ finger strikes joint of middle finger on non-dominant hand

Non dominant hand.. middle finger... middle finger

Percussion sound from the stomach intestine that is loud and high pitch

Tympany

Normal lung percussion sound thay is medium loud and low pitch

Resonant

Percussion sound of the liver, spleen high pitch but soft

Dull

Percussion sound of


-adult lungs increased air (COPD)


-normal over child lung


Louder intensity lower pitch

Hyper-resonant

Listening to sounds produced by the body using a stethoscope

Auscultation

Name the four characteristics of sound

Pitch quality loudness duration

Areas assessed for _______ are the heart, blood vessels, lungs, abdomen

Auscultation

The diaphragm on a stethoscope is for _____ pitch sounds such as breath, bowel and normal heart sounds

High

Use the bell for ____ pitched sounds e.g. extra heart sounds, murmurs, bruits in arteries

Low

4 Areas of a general survey include

1 physical appearance 2 body structure 3 mobility 4 behavior

Age, gender, level of consciousness, skin color, and facial features are included in the _______ _______ area

Physical appearance

Stature, nutrition, symmetry, position, posture, body build, contour, obvious physical deformities are apart of the area ____ ____ in general survey

Body structure

Observing the gait and range of motion are included in the area of ______ in general survey

Mobility

Observing the facial expression, mood in effect, speech, dress, and personal hygiene are a part of ______ in general survey

Behavior

Vital signs include...

Temperature, pulse respirations, blood pressure

If waist circumference surpasses __inches in female and ___ inches in male there is an increased risk for cardiovascular disease

35 f 40 m

How to calculate BMI

Weight (kg)/height (meters)^2


What part of the brain is in charge of body temperature and balances heat production(metabolism exercise food ingestion external factors) and heat loss (radiation evaporation of sweat convection and conduction)

Hypothalamus

Normal oral range

98.6 F normal avg


94.6 - 99.1

is a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature.

Hypothermia

What are the characteristics of a symptom

Location, quality, quantity, setting, timing, perception

What is functional assessment

Assessment of how a person manages day-to-day activities an important part of a health history of an older adult

What is the purpose of the review of systems section of health history

To evaluate the past and present state of each body system, to double check in case significant data where omitted to present illness section, to evaluate health promotion practices

______ is the first step in assessment

Inspection

Components of general survey

Nutrition, speech, posture, level of

What sinuses do you palpate upon assessment

Frontal and maxillary

Sound made by indirect percussion over lung tissue

Resonant

Orthostatic hypotension is when ?

When the blood pressure is taken lying, sitting, and standing and the systolic BP drops > 20mmhg when changing positions from sitting to standing

Note some common errors in BP measurement causing high diastolic pressure

Deflating BP cuff to slowly Allowing person to support own arm Legs crossed failure to repeat 1-2 min after reading

The epidermis is replaced every ....

4 weeks

Xerosis is another name for

Excessively dry skin

Shingles are a

Zosteriform (herpes like) rash across the torso

ABCDE in skin assessment stands for

Asymmetry, Border, Color change, Diameter (greater than 6mm), Elevation/enlargement

Pallor(pale color) is noted in these areas of people with darker skin

Areas with least pigmentation. .conjunctiva, mucous membranes etc

Six cardinal positiobs of gaze tests what cranial nerves

CN 3,4 and 6

This test involves the twinkle of light on eyes bilaterally

The hischberg or corneal light reflex

Prebycusis is when..

The gradual sensorineural loss caused by neeve damage om the inner ear that slowly progresses after the 5th decade

3 parts of the PERRLA test

Pupils round and equal


Pupils react equally to light (direct and consensual)


Pupils constrict and axes of eyes converge when shifting gaze from far to near object

Ostosclerosis is ...

A common type of hearing loss in young adults between 20-40 years

This should be midline on inspection and requires palpation of the neck

Trachea

Touching the posterior wall of the pharnyx with tounge blade elicits gag reflex this tests what CNs

CN 9 & 10

How to check the carotid artery for presence of bruits

Use bell of the stethoscope to assess the neck

Assessing muscles of masication by trying to open jaw tests what part of this cranial nerve?

CN 5

Formula changing degress from F to degrees C=...

C= 5/9 (F-32)

Changing degrees C to degrees F ... F=...

F= (9/5 × C) + 32

Overheating of body.. body is no longer able to regulate internal temp ..symptoms include muscle cramps, fatigue, dizziness, headache, vomiting, and weakness

Hyperthermia

The heart pumps ~__mL of blood with each heart beat this is called the _________

70, stroke volume

The force of pumping expands the arterial wall and causes a pressure wave called ___ _______

The pulse

Use pads of first 3 fingers at flexor aspecr of wrist laterally along radial bone, press until you feel strongest puslation.. this is called measuring the _____ ______

Radial pulse

Asses pulse for 4 qualities...

R.R.F.E. rate, rythm,force, elasticity

Normal pulse rate for adults range from...

60-100

Less than 60 bpm..

Bradycardia

More than 100 bpm

Tachycardia

When assessing the _____ of pulse, you will usually observe an even tempo, note if it is regular or irregular

Rhythm

The normal force of a pulse is

2+

Pulse force measurements include..

0- absent...1+weak and thready... 2+ normal ....3+ full

Apical(heart/chest) pulse rate minus radial rate is the

Pulse deficit

Systolic pressure minus diastolic pressure reflects the ____ _____ and is called _____ ______

Stroke volume, pulse pressure

Obtain the _____ ______ by two peole simultaneously taking apical rate and radial rate

Pulse deficit

Indicates a weak contraction of the ventricals, occurs with atrial fibrillation, premature beats and heart failure

Pulse deficit

Respirations are involuntarily controlled by the repiratory center in the brain stem in the ___ and _______

Pons and medulla

Normal respiration rate for adults..

10-20 breaths/min

A potentially serious sleep disorder in which breathing repeatedly stops and starts

Apnea

Slow breathing a decreased but regular rate less than 10 per min

Bradypnea

Easy Free restoration as is observed normally under resting conditions normal quiet breathing

Eupnea

A cycle in which respirations gradually wax and wane in a regular pattern increasing in rate and depth and then decreasing the breathing. / 30 to 45 seconds with the periods of apnea lasting 20 seconds alternating the cycle ..the most common causes severe heart failure others are renal failure meningitis drug overdose and increased intracranial pressure

Cheyne-stokes respirations

Rapid slow breathing increase rate 24 breaths per minute a normal response to fever fear exercise also happens with respiratory insufficiency pneumonia and lesions on the pons

Tachypnea

Heart rate (HR) × Stroke volume (SR) =

Cardiac output

Maximum pressure felt on the artery during the left ventricle contraction or systole

Systolic pressure

Elastic recoil or resting pressure that blood exerts between each contraction

Diastolic pressure

Pre hypertension .. systolic ____ & diastolic ___

121-139 systolic & 81-89 diastolic

Hypertension #/#

140/90 or greater

Age, race, weight, emotions, sex, diurnal, exercise, stress all affect

Blood pressure

When vessel walls are stiff/rigid Bp ..

Increases

When the blood has a high viscosity BP

Increases

Orthostatic or postural hypotension is a srop in systolic pressure more than -- mmHg due to abrubt change in peripheral vasodilation w/o CO compensating

20

The width of the rubber bladder should be ____ of the arm circumference

40%

The length of the bladder is ___ of the circumference

80%

First sound heard when taking blood pressure

Systolic

Second sound documented when taking blood pressure aka disappearance of sound

Diastolic

In Korotkoffs sounds, the first sound is _______ aka systolic pressure

Tapping, soft clear, increase in intensity

In Korotkoffs sounds the number 2 sound is ______ which is turbulent blood flow that is a softer murmur thay follows the taping

Swooshing

In Korotkoffs sounds number 3 is ______ which is crisp high pitched sounds

Knocking

In Korotkoffs sound (number 4) mutes to a blowing

Abrubt muffling

5th Korotkoff sounds is the last audible sound ..diastolic pressure

Silence

Rest supine for 2 to 3 minutes take blood pressure, sit up and rest 2 to 3 minutes take blood pressure, stand up and rest 2 to 3 minutes to take blood pressure is how to take

Orthostatic BP

CN # ???

1

CN?

2

CN?

3 oculomotor 4 trochlear, 5 abducens

CN?

5 trigerminal

CN?

7

Ear CN?

8

CN?

9, 10

CN?

11 XI

CN ?

12

Thigh bp.. rest prone wrap (18-20cm) around lower 1/3 thigh place diaphragm on popliteal artery. . The ______ pressure is 10-40 mm Hg higher than the aem

Systolic

BP of the thigh might be measured because they compare the arm pressure to the thigh pressure to check for _______ of the aorta

Coarctation

Aging adults have -------- systolic pressure from a stiffer aorta

Higher

A measurement of arterial oxygen (O2) saturation

Pulse oximeter

Normal % of O2 saturation ..

..97-98%

This method is used especially to locate peripheral pulse sites when palpating is difficult or unable to be done

Doppler ultrasonic flow meter

This is a ... used for...

What are a couple things someone might do to prevent HTN or manage it?

6. Maintain adequate dietary Ca and Mg


7. Stop smoking


8. Reduce diet intake of saturated fat and cholesterol

Fill in the blank

Calcium

Fill in the blank

Magnesium

The three layers of skin are

Epidermis, dermis, subcutaneous

Name term

Epidermis

Second layer of skin

Dermis

Term layer of skin

Subcutaneous layer

Name some functions of the skin

What term

Freckles

Name term

Mole

Where to assess for color changes on body

_______ is seen in mucous membranes ,lips , & nail beds

Pallor

Pallor of anemia seen in

Palpebral conjunctiva and nail beds

Intense redness from excess blood (hyperemia) in dilated superficial capillaries in darker skin people there is a purplish tinge, best to palpate for warmth

Erthema

Bluish mottled color .. decreased perfusion with oxygenated blood in dark skin itll be dark but dull best to check conjunctiva, oral mucusoa, nail bed

Cyanosis

Yellow color. . Rising amount of bilirubin. Check darker skin on junction of han, soft palate and mouth

Jaundice

If cold skin temp or HYPOTHERMIA is local that means

Peripheral artery insufficiency

If the skin is generally _______ aka _______ this could mean a circulatory collapse

Cold , hypothermia

Means profuse pespiration

Diaphoresis

For ______ look for mucous membranes that look dry, lips look parched and cracked, in extreme skim fissures

Dehydration

For hypothyroidism skin texture feels..

Rough, dry, flaky

For hyperthyroidism skin texture is

Smooth, softer, like velvet

When someone has arterial insufficiency thier skin is...

Thin, shiny

Fluid in intracellular space; not present normally

Edema

The scoring chart for ______ is *pic*

Edema

Heart failure and kidney failure could cause bilateral ____

Edema

Skins ease in rising

Mobility

Skin return to place promptly

Turgor

Poor turgor may mean

Dehydration or wieght loss

If lesion is found on inspection note the

These lesions are linear and along nerve routes aka...

Zosteriform

These lesions are annular and run together

Polycyclic

These lseions are like scrathes or streaks

Linear

This type of lesion contains concentric rings

Target or iris

This type of lesion is twisted or coiled

Gyrate

Confluent means

Run together

Encapsulated fluid-filled; elevated ..

Cyst

Sulerficial red raised edema within called

Wheal

Wheals that coalesce (hives) lesion called

Urticaria

A nodule that is more than a few cms

Tumor

Pruritis means

Itching skin

Turbid pus fluid; elevated circumscribed eg. Acne

Pustule

Elevated with free flowing fluid less than one cm eg. Blister

Vesicle

Solid; elivated into dermis more than 1 cm

Nodule

These type of skin lesions include macules papules plaque patch nodule wheel hives tumors vesicle bulla cysts and pustules

Primary

These type of skin lesions include crust, scale, fissure, erosion, ulcer, excoriation, atrophic scar, scar, pressure ulcers, keloid, lichenification..

Secondary

Endocrine abnormalities can cause

Abesnt or sparse genital hair or excess body hair (hirutism)

When a lesion develops on previously unaltered skin it is

Primary lesion

when a lesion changes over time or changes because of scratching or infection it is

Secondary lesion

________ of nails occur when a pt has cyanotic heart disease, lumg cancer ans pulmonary disease

Late clubbing

The distribution of hair across our body should be

Fine vellus

Subcutaneous skin layer thins in the aging adult causing

Risk of hypothermia and increase risk of pressure ulcers

The number of active epidermis melanocytes decrease so older adults have...

Increased susceptibility to sun exposure

In older adult might have more susceptible dry skin and decreased sensation of pain / touch / temperature from the _____

Decreased profusion of the dermis

Aging adults get dry wrinkled skin from ...

Decreased turgor and decreased subaceous glad activity

Increased cell production in normal tissue

Hyperplasia

Hypopigmentation occurs on the elderly aka age spots occurs on _____ especially

Hands

This is

Shingles (herpes zoster)

For people who are over 65 years old and have had chickenpox before you would advise them to ______ to prevent shingles

Healtht diet exercise keep immune system healthy get vaccinated

The shingles complication that causes continued pain even after the rash has cleared

Post-herpetic neuralgia

What does ABCDE rule stand for in skin self-examination

Name

Basal cell carcinoma

Name

Squamous cell skin cancer

Name

Melanoma

Term

Melanoma

Alopecia means

Hair loss

Ecchymosis means

Raised bluish or yellowish vadcular lesions

Erythema means

Reddening of skin

A pigment produced by keratinocytes

Keratin

Oily substance secreted by sebaceous glands

Sebum

Urticaria is

Patches of pale itchy wheals in erythematous area

Vitiligo means

Abnormal loss of melanin in patches

Number one cause in traumatic brain injury TBI

Falls

Cranial nerve injury, bacteria and Drews cranial vault, cerebrospinal fluid are examples of

Intracranial trauma

The muscle that flexes and rotates head

Sternocleidomastoid

Raises scapula (shoulder blade) as when you shrug your shoulders or pull head up backwards muscle

Trapezius

Partiod, submxillary, and submandibular are ______ glands

Salivary

Name lymph nodes

Preauricular

Name lymph nodes

Posterior auricular

Name lynph infront of occipital

Jugulodigastric

These two nodes are called

Superficial cervical

These 2 lymphs are called

Submandibular

Lymph is called

Submental

These lymphs are called the ..

Deep cervical chain

These 3 lymphs are

Posterior cervical

That lymph is called

Supraclavicular

Ask person to smile, frown, close eyes tight, loft eyebrows, sho re teeth puff cheeks air comes out bilaterally tedtingr for CN

VII cn7

This is the

Palpebral fissure

When you push down on jaw and try to seperate it while it clenched you are testing CN

V , 5

This is the

Nasolabial folds

By resisting examiners hands on shoulder as persons shrug you are testing for cranial nerve

XI ,11

There is a dramatic increase in _____ cancer in females 30 to 60 years old

Thyroid

The two risk factors of thyroid cancer is

Large dose of radiation expecially as child parent or sibling with history of thyroid cancer

Signs and symptoms of this disease is difficulty swallowing or breathing, hoarseness, lingering cough unrelated to a cold, pain or lump or swelling or fullness in the neck 15 percent to 30 percent of woman have a nodule 97% of time it is curable

Thyroid

This is the _______ w hi ch is between the sternocleidomastoid muscle and trachea

Cartoid artery

Corner of the eyes angle where lids meet

Canthus

Thin mucous membrane; transparent protective covering of eyeball and mucous membrane

Conjunctiva

T hi s is called the

Lacrimal apparatus

Fibrous protective white covering internal anatomy of eye

Sclera

Covers iris and pupil

Cornea

Visual receptive layer in which light waves are changed into nerve impulses inner layer of eye

Retina

Area in which retinal fibers converge to form optic nerve

Optic disc

On temperol side od the fundus; recieves & transduves light from the center of the visual field

Macula

the normal constriction of the peoples when bright light shines on the retina

Pupillary light reflex

When one eye is exposed to bright light a ____ reflex construction of that people

Direct

Simultaneous construction of the other people when direct light is exposed to the other eye visual reflex

Consensual

A reflex direction of the eye toward an object attracting our attention visual reflex

Fixation

Adaption of the eye for near vision it is accomplished by increasing the curvature of the lens through the muscles of the ciliary body

Accommodation

The perception of two images of a single object

Diplopia

Testing peripheral vision is testing CN

II , 2

This test is called...Assess parallel alignment of eye axes by and shining light towards persons eye have patient stare straight ahead hold light about 12 inches away so no lights were the person I'm normal reflection on cornea should be in exactly the same spot on each eye abnormal would be asymmetry of light relfex deviation in alignment due to eye muscle weakness or paralysis

Hirschberg test .. corneal light reflex

Crainial nerve.. eye turning down and temporal and...

3

Cn ?

VI .. 6

Craniak nerve?

IV , 4

An abnormal fine osculating movement seen in iris in eye

Nystagmus

Unequal sides peoples 5 percent of people have this

Anisocoria

Some things that happen to the eyes of an aging adult

Cataracts 75 to 85 year olds glaucoma increased intraocular pressure, macular degeneration or loss of central but not peripheral vision 75 85 year old are all common causes of..

Decreased visual function in aging adults

Eye lens loses ability to change shape to accommodate to near vision loses elasticity lens becomes hard glass-like begins around 40 years old condition called

Presbyopia

Gray white arc or circle around the lumbus caused by deposition of lipid material is called

Arcus senilis

This part of the external ear funnels sound waves

Auricle or pinna

Tympanic membrane up early grey color separates external from middle ear also called

Ear drum

Yellow waxy material lubricates and protect tympanic membrane

Cerumen

This tube connects middle ear to nasopharynx allows air passage during swallowing and yawning

Eustachian tube

These three structures in the middle ear are

Malleus, incus, and stapes in oval window

Inputting ear drops in and child you would pull the pinna ____ and ____

Down and back

Putting teardrops in an adult you would pull the pinna ___ & _____

Up and out

The vibrations are transferred by the chain of auditory ossicles and then into the stapes which is surrounded by the skin labyrinth of the inner ear the organ of Corti in the cochlea is stimulated by this and the impulse is carried by nerves to the core of cranial nerve #

8 , VIII

The normal pathway of hearing is

Air conduction

Staggering gate and strong spinning whirling sensation is called _____ due to inflimation in the ear

Vertigo

A sensorineural loss ages 40 to 80 years from nerve degeneration in the inner ear or auditory nerve

Presbycusis

The common cause of conductive hearing loss in young adults ages 20 to 40 years from gradual hardening of state and so sound transmission cannot occur unless amplitude greatly increase

Otosclerosis

Three types of hearing loss from obstruction of sound transmission

1 conductive 2 sensorineural 3 equilibrium

Ototoxic hearing loss can be caused by which drugs

In the aging adult what would you encourage to prevent hearing loss

regular otoscopic exams of aging

Ringing cracking or buzzing heard sound in ear is called

Tinnitus

Divides nasal cavity into two slits

Septum

Bony projections in the lateral wall of nose are caused

Turbinates

The functions of the nose are

Warms moistens and filters inhaled air

Midline tissue connects tongue to mouth floor

Frenulun

That is the

Uvula

How many permanent teeth in adult

32

Four air-filled pockets in the cranium called

Paranasal sinuses

Purple sinuses

Ethmoid sinuses

What sinus is this

Sphenoid sinus

Largest salivary gland with in cheek in front of ear. Pink

Partiod gland

The salivary glands beneath mandible at jaw angle green

Submandibular glands

The salivary gland in the floor of the mouth under tongue

Sublingual

Part of throat blue shaded contains adenoids and eustachian tube openings

Nasopharynx

Nose bleeds scientific name

Epitaxis

This part of the throat contains tomsils mass of lymphoid tissue

Oropharynx

Tonsil grading... 1+ means .. 4+ meanss

Nose mouth and throat changes in the aging adults

Occlude one nares and have one person sniff inward through other nearest this is testing cranial nerve

1

Touch the posterior pharnyx to wall to test the gag reflex have a person saying ahh or yawn


Uvula and soft palate should rise in midline testing for CNS

Cn IX (9) glossopharngeal, and CN X (10) vagus

A sore throat that does not heal a smooth or leathery white patch or lump ..pa pro long sore throat or feeling that something is in the throat difficulty chewing restricted movement of the tongue or jaw are early signs of

Oral cancer