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HA Test #1
Test on February 17
| Question | Answer |
|---|---|
| Communication | All behavior, conscious and unconscious, verbal and nonverbal. All behavior has meaning |
| Sending | Involves verbal and nonverbal messages: posture gesture, facial expression, eye contact, touch |
| Receiving | Receiver interprets message based on past experiences, culture, self concept, and current physical and emotional state |
| Internal factors | what you bring to the interview |
| Liking others | optimistic view of others, unconditional acceptance of patient and their control over their health |
| Empathy | viewing the world from the other person's inner frame of reference while remaining yourself |
| ability to listen | listen to "what" is said, what is "not" said, and to the "way" it is said |
| External factors | privacy, interruptions, physical environment (warm room, good lighting, reduce noise, distance 4-5 feet, face to face position, seated, at eye level, AVOID STANDING), dress, note taking (keep to a minimum), tape and video recording |
| Techniques of communication | introducing the interview, working phase, ten traps of interviewing, nonverbal skills, and closing the interview |
| introducing the interview | state the purpose of the interview |
| working phase | open ended questions; invites narrative response ("tell me how I can help you" or "how have you been getting along"); closed or direct questions request specific info ("are you having pain now") |
| ten traps of interviewing | false assurance or reassurance; giving unwanted advice; using authority; using avoidance language; engaging in distancing; using professional jargon; using leading or biased questions; interrupting & finishing the sentence; using "why" questions |
| closing the interview | "is there anything else you would like to mention" or "are there any questions you would like to ask"; summarize what you have learned during the interview |
| facilitation | "mm-hmm, go on" encourages conversation; also called general leads. shows the person that you are interested and will listen further |
| silence | promotes attentiveness. golden after open ended questions. advantages- letting the person collect their thoughts, gives you a chance to observe the person and note nonverbal cues, and gives you time to plan the next approach |
| reflection | echoes patient's words. helps the person elaborate. |
| empathy | understanding pt's world view. strengthens rapport, and the patient feels understood |
| clarification | my understanding of what you said. you are asking for agreement and the person can then confirm or deny your understanding |
| confrontation | focus on a discrepancy, when parts of the story are inconsistent: "earlier you said you were laying off alcohol and just now you said you had a few drinks after work". focuses on nurse's perspective |
| interpretation | clarifies and promotes discussion. focuses on nurse's perspective. ascribes feelings and helps the person understand his or her own feelings in relation to the verbal message. "seems everytime you have stomach ache, its from being stressed out" |
| explanation | share factual objective information. focuses on nurse's perspective. "the reason you cannot eat or drink before your blood test is that the food will change the test results" |
| summary | a review of what the person just said; focuses on nurse's perspective |
| nonverbal skills | physical appearance (look professional); posture (relaxed posture creates feeling of warmth and trust); gestures (nodding); facial expression (attentive and sincere); eye contact; voice (be aware of tone, intensity, and rate); touch (use with caution) |
| the purpose of the health history | collect SUBJECTIVE data (what the person says about himself/herself). combined with objective data from the physical exam and lab studies to form the database |
| complete health history components | biographical data; source of the history, reason for seeking care; present health or history of present illnesses; past health; family history; review of systems; functional assessment or ADLs |
| biographical data | name, address, phone number, age, birth date, birthplace, gender, marital status, race, ethnic origin, occupation, primary language, and authorized representative (if any) |
| source of the history | record who furnishes information (usually the pt. but could be relative, friend, or caseworker) and note how reliable they are. Note any special circumstances, like the use of an interpreter |
| reason for seeking care | brief, spontaneous statement in the person's own words that describes the reason for the visit. sometimes the pt will list many reasons for seeking care, but just focus on the most pressing concern |
| present health or history of present illnesses | location; character/quality (descriptive- burning); quantity/severity; timing (onset, duration,frequency); setting (what were they doing); aggravating/relieving factors (what makes it better/worse); assoc. factors; patients perception(how it affects ADLs) |
| past health | childhood disease; accident/injuries; serious/chronic illness; hospitalizations; operations; obstetric history (# pregnancies, # reaching full term, incomplete preg., preterm preg, living children); immunizations; last exam date; allergies; current meds |
| family history | will highlight diseases and conditions for which a particular patient may be at increased risk |
| review of systems | evaluate past and present health state of each body system, double check in case any significant date were omitted in the present illness section, and evaluate health promotion practices |
| functional assessment or ADLs | activities of daily living; provide data on the lifestyle and type of living environment which the person is accustomed |
| ADHOC interpreter | friend or family |
| PQRST | provocative or palliative (what brings it on?), quality or quantity (how does it look, feel, sound), region or radiation), severity scale (0-10), timing (onset, duration, frequency), understand patient's perception |
| Recent memory assessment | Assess in the context of the interview by the 24 hour diet recall or by asking what time the patient arrived at the agency. Ask questions you can corroborate because it screens for the occasional person who makes up answers to fill in gaps of memory loss |
| potential for loss occurs in old age from: | loss of job status, loss of income, loss of loved ones, loss of youthful body. Loss can result in grief, despair, and change in mental status |
| The aging adult (mental) | mental status remains mostly intact, no decrease in general knowledge or loss of vocabulary, response time slows, takes longer to respond to questions, slower response time affects new learning, RECENT memory decreases w/ age, REMOTE memory not affected |
| delirium | disturbance of consciousness (reduced awareness of environment with reduced ability to focus or shift attention). can be very sudden, be fine one day and very confused the next |
| abnormalities of mood and affect | flat affect (lack of emotional response); depression; elation (joy and optimism, overconfident), euphoria (excessive sense of well being, implies a pathologic mood), anxiety (apprehensive from the anticipation of a danger whose source is unknown) |
| objective data main components | ABCT; appearance, behavior, cognition, thought process |
| appearance | posture erect and position relaxed, body movements voluntary and deliberate, dress appropriate for setting & season, grooming and hygiene |
| behavior | LOC (awake, alert, responsive to stimuli), facial expression is appropriate, speech (articulates clearly), mood and affect (language, facial expression) |
| cognition | orientation (person, place, time), attention span (ability to concentrate), recent memory (24 hour recall), remote memory (past health), new learning (4 unrelated words test i.e. fun, carrot, ankle loyalty- 5 min recall) |
| Thought processes and perceptions | thought process (way a person thinks should be logical, goal directed, coherent, and relevant), thought content (what he person says should be consistent and logical), perceptions should be consistent with reality, screen for suicidal thoughts |
| A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Information that would be helpful prior to procedure would include: | reactions to previous hospitalizations. |
| As part of the health history of a 6-year-old male here for a sports physical, you review his immunization record. You note that his MMR (measles-mumps-rubella) was at 15 months of age. What recommendation would you make? | MMR needs to be repeated at age 4 to 6 years. |
| When obtaining a health history on an 87-year-old female, which of the following questions would be most useful? | Current health promotion activities |
| In recording the childhood illnesses of a patient who denies having had any, which of the following would be most accurate? | Patient denies measles, mumps, rubella, chicken pox, pertussis, or strep throat. |
| Which of the following statements best describes the purpose of a health history? | To provide a database of subjective information about the patient’s past and present health. |
| When incorporating the person’s spiritual values into the health history, which of the following questions illustrates the “community” portion of the FICA questions? | “Are you a part of any religious or spiritual congregation?” |
| During your assessment, you use the CAGE test. Your patient answers “yes” to two of the questions. What could this be indicating? | You should suspect alcohol abuse and continue with a more thorough substance abuse assessment. |
| The CAGE test | The CAGE test is known as the “cut down, annoyed, guilty, and eye-opener” test. If a person answers yes to two or more of the four CAGE questions, you should suspect alcohol abuse and continue with a more complete substance abuse assessment. |
| In performing a functional assessment on an 82-year-old patient with a recent stroke, which of the following questions would be most important to ask? | Are you able to dress yourself? |
| When a patient is describing his symptoms, which of the following statements reflects a description of the setting of his symptoms? | “This pain happens every time I sit down to use the computer. |
| In response to your question about stress, a 39-year-old female tells you that her husband and mother both died in the past year. Your response might include which of the following? | “What did you do to cope with the loss of both your husband and mother?” |
| You are assessing a 75-year-old male. As you begin the mental status portion of your assessment you would expect: | it may take him a little longer to respond but his general knowledge and abilities should not have declined. |
| In your assessment of aging adults, you know that one of the first things that you should assess prior to making judgments about their mental status is: | sensory perceptive abilities. |
| Mrs. K. is admitted to your unit following an automobile accident. You begin her mental status examination and find that her speech is dysarthric and she is lethargic. Your best approach regarding this examination is to: | plan to defer the rest of the mental status examination. |
| In your interview with Mr. W. it will be important for you to ascertain some basic history information. Which of the following would you explore more fully with Mr. W.? | Mr. W. states that he “never did too good in school.” |
| Mr. D. has been in the ICU for 10 days. He has just been moved to your floor and you are planning to perform a mental status examination on him. During the tests of cognitive function you would expect that he: | will be oriented to place and person but may not be certain of the date. |
| Mrs. A., 45, is at your agency for a mental status assessment. In giving her the Four Unrelated Words Test, you would be concerned if: | she could not recall four unrelated words after a 30-minute delay. |
| You are performing a mental status assessment on R., a 5-year-old girl. Her parents are undergoing a divorce and are worried about the effect it is having on R. Of the following info, which statement might lead you to worry about R.’s mental status? | R.’s mother states that R. prefers to play with toddlers instead of kids her age while in daycare. |
| Mr. S. has suffered a CVA (stroke). He is trying very hard to communicate with you. He seems driven to speak and says, “I buy obie get spirding and take my train.” What is the best way to communicate with Mr. S.? | Support his efforts to communicate and use pantomime and gestures to communicate when you can. |
| Your patient is schizophrenic. During a recent interview, he shows you a picture of a man holding a decapitated head. He describes this picture as horrifying and laughs loudly at the content. This behavior is a display of: | inappropriate affect. |
| Mr. H. states, “I feel sad all of the time. I'm not happy even doing things I used to like.” He states he is tired, sleeps bad, has no energy. To differentiate b/w dysthymic disorder & a major depressive disorder, what other areas should you assess? | “How long have you been feeling this way?” |
| You are preparing to assess your patient’s abdomen by palpation. How should you proceed? | Start with light palpation to detect surface characteristics and to accustom the patient to being touched. |
| When performing a physical assessment, the technique you will always use first is: | inspection. |
| You hear bilateral hyperresonant tones when percussing over the thorax of a 4-year-old child. You would: | consider this a normal finding for a child this age and proceed with the examination. |
| Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations? | Palpation |
| You are unable to palpate the right radial pulse on a patient. You would: | use a Doppler to check for pulsations over the area |
| You are unable to identify any changes in sound when percussing over the abdomen of an obese patient. You would: | move to a new body location and attempt to percuss again. |
| You are assessing a patient’s skin during an office visit. What technique should you use to best assess the temperature of his skin? | Use the dorsal surface of your hand because the skin is thinner here than on your palms. |
| You are examining a patient’s lower leg and note a draining ulceration. Which of the following actions is most appropriate in this situation? | Wash your hands, put on gloves, and continue with the examination of the ulceration. |
| Mr. S. is at the clinic for a physical examination. He states that he is “very anxious” about the physical exam. What steps can the examiner take to make him more comfortable? | Appear unhurried and confident when examining Mr. S. |
| During the examination, it is often appropriate to offer some brief teaching about the patient’s body or your findings. Which of the following statements is most appropriate? | “Your pulse is 80 beats per minute. This is within the normal range.” |
| When assessing an 80-year-old male patient, which of the following findings would be considered normal? | The presence of kyphosis and flexion in the knees and hips |
| A 60-year-old male has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an “unexplained” weight loss of 10 pounds over the last 6 weeks. You know that: | Unexplained weight loss often accompanies short term illnesses |
| When assessing a 15-year-old asthmatic patient, you note that he assumes a tripod position, leaning forward with arms braced on the chair. Based on this observation you would: | Recognize that a tripod position is often used when a patient is experiencing respiratory difficulties |
| You are assessing the vital signs of a 20-year-old marathon runner. You document the following vital signs: temperature—97º F; pulse—48 BPM; respirations—14/minute; blood pressure—104/68. Which of the following statements is true? | These are normal vital signs for a health, athletic adult |
| A student is late for his appointment and has rushed across campus to your clinic to have his vital signs assessed. Your first step should be to: | Allow him time to relax and rest 5 minutes before checking his vital signs |
| Your patient’s blood pressure is 118/82. He asks you to explain “what the numbers mean.” You reply: | The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts |
| You are taking an initial blood pressure on a 72-year-old patient with documented hypertension. How should you proceed? | Inflate the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappeared |
| When auscultating the blood pressure of a 25-year-old, you hear the Phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg the Korotkoff sounds disappear. How should you record this patient’s blood pressure? | 200/92 |
| A 70-year-old male has a blood pressure of 150/90 in a lying position, 130/80 in a sitting position, and 100/60 in a standing position. Interpret these findings. | The change in blood pressure readings is called orthostatic hypotension |
| An infant's respirations should be counted by: | Watching the abdomen for movement |
| A 65-year-old male with emphysema and bronchitis has come to your clinic for a skin assessment. You might expect to find the following: | clubbing of the nails |
| When assessing inflammation in a dark-skinned person, it may be necessary to | palpate the skin for edema and increased warmth |
| A black patient is in the intensive care unit because of impending shock after an accident. How would you expect her skin to appear as you assess her? | Ashen, gray, or dull |
| A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. You will encourage her to stop trying to remove the corn with her scissors because: | she could be at increased risk for infection and lesions because of her chronic disease. |
| During a skin assessment, you notice that a Mexican-American patient has skin that is yellowish-brown in color. However, the skin on the hard/soft palate is a normal pink color. From this finding, you could probably rule out: | jaundice. |
| A 40-year-old female reports a change in mole size, with color change, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. You would: | refer the patient due to the suspicion of melanoma based on her symptoms. |
| A newborn is in the clinic for a well-baby check. You are concerned about the possibility of fluid loss because you know: | the newborn’s skin is more permeable than that of the adult. |
| Mrs. P. is leaving on a trip to Hawaii and has come in for a checkup. During your examination you notice that she is diabetic and takes oral hypoglycemic agents. She needs to be concerned about which of the following? | A discussion of the importance of sunscreen and avoiding direct sunlight |
| You are bathing an 80-year-old man and you notice that his skin is wrinkled, thin, lax, and dry. This finding would be related to: | an increased loss of elastin and a decrease in subcutaneous fat in the elderly. |
| A patient comes to your clinic and states that he has noticed that his skin is redder than normal. You understand this condition to be due to hyperemia, and know that it can be caused by: | excess blood in the dilated superficial capillaries. |
| A patient’s thyroid is enlarged, and you are going to auscultate the thyroid for the presence of a bruit. A bruit is a: | soft, whooshing, pulsatile sound best heard with the bell of the stethoscope. |
| You notice that your patient’s submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, you would assess the: | area proximal to the enlarged node. |
| You notice that an infant has a large, soft lump on the side of his head & his mother is concerned. She tells you that she noticed the lump about 8 hours after her baby’s birth, and that it seems to be getting bigger. One possible explanation for this is: | cephalhematoma. |
| You are assessing a 7 yr old with chronic watery eyes, sneezing, and clear nasal drainage. You note the presence of a transverse line across the bridge of nose, dark blue shadows below eyes,& a double crease on the lower eyelids. These findings are from: | allergies |
| The two pairs of salivary glands that are accessible to examination on the face are: | parotid and submandibular. |
| Your patient says she has recently noticed a lump in the front of her neck below her “Adam’s apple” that is getting bigger. During your assessment, the finding that reassures you that this may not be a cancerous thyroid nodule is that the lump (nodule): | is tender. (mobile and not hard. Suspect any painless, rapidly growing nodule, especially the appearance of a single nodule in a young person as cancerous. Cancerous nodules tend to be hard and are fixed to surrounding structures.) |
| Mrs. Phillips brings in her 2-month-old daughter for an exam and says, “My daughter rolled over against the wall and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?” Your response would be: | “That ‘soft spot’ is normal, and actually allows for growth of the brain during the first year of your baby’s life. |
| The temporomandibular joint is just below the temporal artery and anterior to the: | tragus |
| The four areas in the body where lymph nodes are accessible are the: | head and neck, arms, inguinal area, and axillae |
| Mr. J. approaches you to ask a question, and you notice that he seems to have an enlarged and rather thick skull. You wonder about acromegaly, and would continue to assess for: | coarse facial features. |
| Movement of the extraocular muscles is: | stimulated by CN III, IV, and VI. |
| A mother asks when her newborn infant’s eyesight will be developed. You reply: | “By about 3 months, infants develop more coordinated eye movements and can fixate on an object.” |
| A 52-year-old patient describes the presence of occasional “floaters or spots” moving in front of his eyes. | know that “floaters” are usually not significant and are caused by condensed vitreous fibers. |
| You are preparing to assess the visual acuity of a 16-year-old patient. How would you proceed? | Use the Snellen chart positioned 20 feet away from the patient. |
| When performing the corneal light reflex assessment, you note that the light is reflected at 2 o’clock OU. You would: | consider this a normal finding. |
| You note the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. You would: | ask the patient if he or she has a history of heart failure |
| A 68 yr woman is in eye clinic for checkup. She tells you she has trouble with reading paper, sewing,& seeing the faces of her grandchildren. On exam, you note she has some loss of central vision but peripheral vision is normal. These findings suggest tha | she may have macular degeneration |
| Which of the following statements regarding visual pathways and visual fields is true? | The image formed on the retina is upside down and reversed from its actual appearance in the outside world. |
| When a light is directed across the iris of the eye from the temporal side, the examiner is assessing for: | the presence of shadows, which may indicate glaucoma. |
| A patient is unable to read the 20/100 line on the Snellen chart. You would | shorten the distance between the patient and the chart and ask him or her to read the smallest line of print possible. |
| Inspection | critical observation of the patient in a systematic, deliberate manner that begins as a "general survey" the moment the practitioner first meets the patient. ALWAYS use light source. compare right side to left side to determine symmetry. Don't rush |
| Palpation | Use of touch to determine the texture, temp, size, consistency, and location of body parts |
| Fingertips during palpation | best for fine tactile discrimination (skin texture, swelling, pulsation, determining presence of lumps) |
| Grasping action of the fingers and thumb during palpation | detect position, shape, consistency of an organ or mass |
| The dorsa (backs) of hands and fingers during palpation | Determining temperature because the skin here is thinner than on the palms |
| Base of fingers (metacarpophalageal joints) or ulnar surface of hands during palpation | Best for vibration |
| Bimanual palpation | Requires the use of both of your hands to envelop or capture certain body parts or organs (kidneys, uterus, or adnexa) |
| light palpation | used to evaluate surface characteristics and identify any areas of tenderness |
| deep palpation | palpate an organ or mass deeper within a body cavity |
| Percussion | technique of striking a part of the body with, short, sharp taps of the fingers. Used most frequently to assess the thorax and abdomen |
| direct percussion | used to assess the adult sinuses. technique of striking the finger or hand directly against the body |
| indirect percussion | used more often and involves both hands. The striking hand contacts the stationary hand fixed on the person's skin |
| Resonant percussion | medium loud amplitude, low pitch, clear & hollow quality |
| Hyperresonant percussion | louder amplitude, lower pitch, booming quality |
| tympany percussion | loud amplitude, high pitch, musical and drumlike (kettle drum) quality |
| dull percussion | soft amplitude, high pitch, muffled thud |
| flat percussion | very soft amplitude, high pitch, dead stop of sound & absolute dullness quality |
| Parts of a general survey | physical appearance, body structure, mobility, behavioral assessment |
| physical appearance | age, gender, LOC (level of consciousness- person, place, time), skin color, facial features, signs of distress |
| body structure | stature (height), nutrition (weight), symmetry, posture, position (sits comfortably, arms relaxed), body build (arm span- fingertip to fingertip equals height) |
| Mobility | gait (smooth, even and well balanced), range of motion (full mobility of each joint, no involuntary movements) |
| behavior | facial expression, modd and affect, speech, dress, personal hygiene |
| children and general survey | observe interaction with accompanying adult- unexpected behavior on the part of the child or adult can be a sign of child abuse, mental illness, or a developmental disability |
| the aging adult and general survey | less likely to have a fever but at greater risk for hypothermia b/c sweat gland activity is diminished, weight decreases w/ age (especially in men b/c of fat distribution changes), gait (bad balance causes wider gait) |
| the aging adult and general survey (respirations and BP) | respirations (shallower inspiratory phase and an increased respiratory rate) and BP (arteries harden w/ age and BP increases) |
| elderly skin | loses elasticity (folds and sags). By 70s and 80s it looks parchment thin, lax, dry, and wrinkled. Reduction in muscle. Loss of collagen= increased risk for shearing, tearing. Dry skin. Lower response of sweat glands= higher risk for heat stroke |
| lesion | color, elevation (flat, raised), pattern or shape (annular, round, grouped, confluent, linear), size (in cm) location and distribution on body, exudate (color, amount and/or odor) |
| primary lesion | not related to anything the patient has |
| secondary lesion | caused from a condition that the patient has (related) |
| purpose of skin assessment | assess for risk of skin breakdown |
| pressure ulcer stages | stage 1 (stays red), stage 2 (blister), stage 3 (goes into subcutaneous tissue), stage 4 (extends all into supporting tissue and can see muscle and bone) |
| assessment of the thyroid gland | shouldn't feel thyroid (should be non tender and non palpable). Enlarged thyroid (only auscultate if enlarged) from turbulent blood flow and can be listened to with bell of stethoscope. posterior approach, chin up or head back |
| fontanels | feel firm, slightly concaved, and well defined against the edges of the cranial nerves. May see slight arterial pulsations in the anterior fontanel |
| abnormal fontanels | depressed and sunken fontanels occur with dehydration or malnutrition. True tense or bulging fontanel occurs with acute increased intracranial pressure |
| lymphadenopathy & acute, chronic, and cancerous infection | disease of lymph nodes w/ enlargement > 1 cm from infection, allergy, neoplasm. Acute (nodes bilateral, enlarged, warm, tender, firm but freely moveable), chronic (tuberculosis- TB nodes clumped), cancerous (nodes are hard, nontender, unilateral, fixed) |
| layers of the eye | sclera (fibrous outer layer), choroid (middle layer), retina (inner layer) |
| sclera | tough, white covering that protects and supports eyeball. cornea= sensitive to touch |
| choroid | vascular area that delivers blood to the retina, enable the eye to focus on far & near objects, upil= hole in center of iris that allows light to enter (regulated by autonomic nervous system), cranial nerve III (occulomotor) causes constriction of pupil |
| retina | retina functions as the visual receptive layer and changes light waves into nerve impulses. optic disc= where fibers from retina converge to form the optic nerve. macula= slightly darker pigmented region |
| intraocular pressure | determined by a balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber |
| pupillary light reflex | normal constriction of the pupils when bright light shines on the retina |
| developmental considerations and the elderly | skin loses elasticity= wrinkling & drooping, pupil size decreases, involution of lacrimal glands= decreased tear production, dryness, and burning |
| most common causes of decreased visual functioning in older adult | 1= cataract formation by age 70; 2=risk of glaucoma increases with age (chronic, open angle glaucoma is most common- causes gradual loss of peripheral vision); 3= macular degenerationcan't read fine print, sew, seeing faces, loss of central vision |
| Corneal light reflex | Hirschberg Test= assesses alignment of the anterior and posterior axes of both eyes; a bright dot of light held 12 inches away from client should be at the same stop on each cornea |
| Snellen eye chart | position person 20 ft away from chart; use opaque card to shield one eye; remove ONLY reading glasses, read through smallest line of letters possible |
| Snellen eye chart normalities | normal visual acuity is 20/20 (means you can read 20 ft what the normal eye could read at 20 ft); numerator= distance the person is standing from the chart; denominator= distance the normal eye could read the particular line |
| recording the Snellen eye chart | Indicate whether any numbers missed, or if corrective glasses were worn. example: OD (right eye) 20/30 -1, with glasses. OD= right eye. OS= left eye. OU= both eyes |
| Extraocular muscles | provide eye movement; 6 muscles for each eye; muscle function= governed by innervation of cranial nerves III (occulomotor), IV (trochlear), and VI (abducens) |
| The capillary beds should refill after being depressed in | 1-2 seconds |
| The configuration for individual lesions arranged in circles or arcs, as occurs with | annular |
| The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually in order to prevent a | reduction of blood supply to the brain |
| The nurse is preparing to assess the lymph nodes of an adult patient. The nurse should instruct the patient to | sit in an upright position |
| While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for | Acromegaly |
| The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to | approach the client posteriorly |
| Identify the facial bone that articulates at a joint instead of a suture | Mandible |
| After assessing the patient's pulse, the practitioner determines the pulse to be "normal". This would be recorded as | 2+ |
| Physical examination begins with a general survey. Which of the following choices contains all aspects of the general survey? | Age, gender, ethnicity, religion, and cultural values |
Created by:
heatherodom12