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NUR151-HealthAsses2
Health Assessment Part 2 - Body Systems
| Question | Answer |
|---|---|
| Hyperopia | farsightedness, |
| Myopia | nearsightedness |
| Presbyopia | impaired near vision in middle-age and older adults, caused by loss of elasticity of the lens and associated with the aging process. |
| Retinopathy | a noninflammatory eye disorder resulting from changes in retinal blood vessels. It is a leading cause of blindness. |
| Strabismus | congenital condition in which both eyes do not focus on an object simultaneously; these eyes appear crossed. Impairment of the extraocular muscles or their nerve supply |
| Glaucoma | intraocular structural damage resulting from elevated intraocular pressure. Obstruction of the outflow of aqueous humor. |
| Macular degeneration | blurred central vision often occurring suddenly, caused by progressive degeneration of retina. Most common visual impairment over 50 and most common cause of blindness in older adults. No cure. |
| Nystagmus | An involuntary, rhythmical oscillation of the eyes, by periodically stopping movement of the finger. |
| You initiate nystagmus in clients with normal eye movements by? | Having them gaze to the far left or right. Disturbances in eye movement reflect local injury to eye muscles and supporting structures or a disorder of the cranial nerves innervating the muscles. |
| Pupils more than __ centimeters is considered dilated. | 3 |
| An abnormal drooping of the lid over the pupil is called __ and caused by edema or impairment of the third cranial nerve. | ptosis (pronounced “toe-sis”) |
| Lid margins that turn out | ectropion |
| Entropion sometimes leads to the lashes of the lid | irritating the conjunctiva and cornea, increasing the risk of infection. |
| When assessing the thorax, use | inspection, percussion, and auscultation. |
| green phlegm is | bacterial |
| white phlegm is | viral |
| rusty phlegm is | TB perhaps or pneumonia |
| pink frothy phlegm is | emphysema |
| Bronchial sounds | Expiration is longer than inspiration to hear this sound. |
| Bronchovesicular sounds | on either side of the sternum. Close to the bronchus in the lung. Moderate pitch sounds. Inspiration should equal expiration. |
| Vesicular sounds | low pitch – sounds like wind through the trees – inspiration long than exhalations. |
| Adventitious Breath Sounds | bad lung sounds |
| Crackles/Rales | Sounds like rubbing your hair in front of your ears or rice crispies. Tend to be in the lower lobes. |
| Coarse/Rhonchi | When you have fluid in the lungs – sounds like someone snoring. Can cough it out, sometimes. |
| Wheezes | airway is constricted – musical sounds – high pitch |
| Stridor | Trachea is closing down – like croup |
| Pleural Friction Rub | when pleura are inflamed and are rubbing together – sounds like rubber squeaking together. Very painful. |
| Diminished/Absent Sounds | not a good thing – could mean there is a mass, pneumothorax. COPD, emphysema |
| Barrel chest | increase anteriorposterior diameter |
| Pigeon chest | anteriorly displaced sternum |
| Funnel chest | Depressed lower sternum |
| Crepitus | when air leaks into the subcutaneous tissue from a chest tube. Tube used for relieving a pneumothorax. This is an air leak that dissipates. |
| Tactile Fremitus | checks sound vibration quality of the lungs – consolidation in the lungs like a tumor or pneumonia, the vibration would be stronger throughout those areas of the lungs. |
| A-P-E-T-M | All, people, eat, tacos, Monday |
| Aortic | Right sternal boarder – 2nd intercostal space |
| Pulmonic | base of heart – left sternal boarder |
| Erp’s (Second Pulmonic area) | Midprecordial area – 3rd intercostals, left sternal boarder |
| Tricuspid | 5th intercostals space – left sternal boarder |
| Mitral | Left 5th intercostal –midclavicular line |
| Identify S1 | “lub” Mitral & tricuspid – AV valve – loudest at apex |
| S2 | ”dub” Semi-lunar valves – best heard at base of heart |
| Trauma, cirrhosis, diabetes mellitus, and hypertension cause __ in nails. | splinter hemorrhages |
| Vitamin, protein, and electrolyte changes cause various ___ to form on the nail beds. | lines or bands |
| Clubbing | Change in angle between nail and nail base (eventually larger than 180 degrees); nail bed softening, with nail flattening; often, enlargement of fingertips. Causes: Chronic lack of oxygen: heart or pulmonary disease |
| Beau's lines | Transverse depressions in nails indicating temporary disturbance of nail growth - Causes: Systemic illness such as severe infection; nail injury |
| Koilonychia (spoon nail) | Con cave curves - Causes: Iron deficiency anemia, syphilis, use of strong detergents |
| Splinter hemorrhages | Red or brown linear streaks in nail bed - Causes: Minor trauma, subacute bacterial endocarditis, trichinosis. |
| Paronychia | Inflammation of skin at base of nail - Causes: Local infection, trauma. |
| JVD | Jugular Vein Distention or Jugular Venous Pulse |
| CVP | Central venous pressure |
| Thrills | vibrations, similar to purring cat |
| Heaves/lift | lifting of the cardiac area |
| Abdominal Assessment Order of assessment | Inspection, Auscultation, Percussion, Palpation |
| Intermittent gurgling sounds throughout the abdomen are a result of | air and fluid movement |
| Borborygmi | high pitch growling bowel sounds – indicates increased gastrointestinal motility. |
| Absent bowel sounds | Auscultate 5 minutes in each quadrant |
| Dullness sound in abdomen | generally heard over a solid organ, mass, full bladder |
| McBurney’s Point | pain in the right lower quadrant - appendicitis |
| Blumberg’s Sign | on left side - rebound tenderness – poke into their abdomen – appendicitis – could also indicate Crone’s |
| Rovsing’s Sign | referred pain in the abdomen - appendicitis |
| Iliopsoas | raise their right leg off the table and push on the thigh, if they have pain there, they have a positive sign. |
| Obturator | raise right leg and raise it out to the side. |
| Murphy’s Sign | Cholycystitis – inflammation of gallbladder – deep palpation with a deep breath under their right rib. |
| CVA/Flank pain | Hand over kidneys and pound on it. If pain, then kidney inflammation. |
| Romberg Test | Stand straight up, feet together, hands at their side, and wait about 20 seconds. If difficulty, could be cerebral ataxia. Or proprioception reception lost - lose their sense of space. |
| Tandem walking | walking heal-to-toe – could indicate neuron lesion, alcohol intoxication, cerebral dysfunction. |
| Babinski Reflex | tickle the bottom of the foot (lateral edge and across the foot) and toes fan as infant until about 24 months. In adult, fanning of toes is wrong. Toes should curl - brain injury indicated if toes fan in an adult. |
| In ear exam, pull ears? | Back and up for adult |
| Excoriation | local skin breakdown |
| Phlebitis | inflammation of vein that occurs |
| The nurse accurately assesses temperature by palpating the skin with the ___ of the hand, because this area of the hand is more sensitive to temperature than is the base of the hands, the fingertips, or the palmar surface. | dorsum or back |
| Pigmented skin lesions that are ___ are lesions that are suspect and should be reported to a medical provider. | asymmetrical, have irregular borders, have variegated colors, and are larger than 6 mm in diameter |
| Rhonchi are? | Loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration. |
| Crackles are? | moist sounds heard during inspiration that are not cleared with coughing. |
| Wheezes are? | high-pitched continuous muscles sounds such as a squeak heard continuously during inspiration and expiration. |
| The closing of the aortic and tricuspid valves is the | S1 sound |
| The S2 (dub) sound is the second heart sound and indicates closure of the | aortic and pulmonic valves |
| The ___ is felt on the top of the foot in line with the groove between the extensor tendons of the great toe and the first toe. | dorsalis pedis pulse |
| The ___ is felt in the groove behind the medial malleolus. | posterior tibial pulse |
| Adduction is | movement toward the body. |
| Abduction is | movement away from the body. |
| Flexion is | movement that decreases the angle of the joint |
| Extension is | movement that increase the angle of the joint. |
| Explaining a saying indicates the client's ability to perform | abstract reasoning. |
| Judgment involves | comparison and evaluation of facts and ideas to understand their relationships and to form appropriate conclusions. |
| Knowledge is | understanding or awareness of information gained through learning or experience. |
| Association involves | finding similarities between concepts. |
| The supine position provides easy access to | pulse sites |
| Resonance is the low, hollow sound of normal | lungs. |
| Hyperresonance can be heard over | emphysematous lungs as a booming sound. |
| Tympany is the high-pitched, drumlike sound heard over a | gastric air bubble. |
| Dullness is the soft, thudlike sound that is heard over | dense organ tissue |
| Pallor would appear as __ in brown-skinned people. | yellowish brown |
| Pallor would manifest as ___ in light-skinned people. | bluish skin |
| Pallor would appear as __ skin in black-skinned people. | ashen gray |
| Shiny skin indicates | edema |
| Kyphosis | (hunchback) is an exaggeration of the posterior curvature of the thoracic spine and is common in older adults. |
| Lordosis | (swayback) is increased lumbar curvature. |
| Scoliosis | is lateral spinal curvature. |
| Hypotonic | muscle has little tone and feels flabby, usually because of atrophy of muscle mass. |
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