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unit 2 reviewer
| Question | Answer |
|---|---|
| to collect subjective and objective data about a patient to determine his/her overall level of physical. | purpose of health assessment |
| a type of assessment that is conducted when a patient first enters a healthcare settings, with information providing a baseline for comparing later assessment. | comprehensive assessment |
| a type of assessment that is conducted at regular intervals (eg, at the beggining of each home visit or each hospital shift. | ongoing partial assessment |
| a dilusional belief that others can hear or know what the client is thinking | thought broadcasting |
| the first thing that a nurse will assess when assessing mental status | general appearance and behavior |
| the capacity to understand and reason | cognition |
| the process by which information and experiences are stored and retrieved | memory |
| the outward expression of the client's emotional state | affect |
| the ability to interpret one's environment and situation correctyly and to adopt one's behavior and decisions accordingly | judgement |
| the ability to understand the true nature of one's situation and accept some personal responsibility for the situation | insight |
| recognition of person, place and time | orientation |
| pervasive and enduring emotional state | mood |
| a dilusional belief that others are putting ideas or thought into client's head- tha the ideas are not those of the client | thought insertion |
| a dilusional beliefs tha others are taking the client's thoughts away and the client is powerless to stop it | thought withdrawal |
| flow of unconnected words that convey no meaning to the listener | word salad |
| diminished visual acuity | presbyopia |
| excess fluid in the tissues, may cause difficulty in lifting the skin fold. Characterized by swelling with tauts and shiny skin, maybe the result of overhydration, heart failure,kidney failure,trauma or periphiral vascular disorder | edema |
| what are the physiologic changes of aging | 1.presbyopia 2.increased sensitivity to glare 3. decreased accomodation, depth perception and color descrimination |
| what are the physiologic chnages of aging | 4. decreased ability to adjust to darkness 5. increased incidents of cataracts. |
| difference between the systolic and diastolic reading. it is an early sign of shock. | pulse pressure |
| what is the difference between apical and radial pulse....0 means normal | pulse deficit |
| irregular heart beat, abnormal or irregular heart rhythm | arrhytmia = dysrhythmia |
| abnormal elevated pulse, or above 100 beat/min | tachycardia |
| abonormal low pulse rate , or below 60 | bradycardia |
| information experiences or known only by the patient and obtained from the patient during the health history | subjective data |
| what is the word used to describe cyanosis in dark skinned people which describes an ashen gray | dusky |
| is a tool used to assess a patient's skin risk for skin breakdown | braden scale |
| what areas are assessed in the braden scale | mental status/ sensory, continence/moisture, nutritional status, mobility and activity level, |
| includes all the pertinent patient information collected by the nurse and other healthcare professional enabling a comprehensive, effective plan of care to be designed and implemented for the patient | database |
| disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts | loose associations |
| term used when there is no abnormal disruption in the skin surface. a disruption maybe a trauma or injury such as laceration or a surgical incission, lesion or open sore | intactness |
| is a thickening and roughness of skin texture. described as a circumscribed lesion or change in skin integrity with errythema, thickening and scaly patches | psoriasis |
| loss of sensation such as numbness, tingling, abnormal feeling | paresthesia |
| wandering off the topic and never providing the information requested | tangential thinking |
| imaginary lines used to describe location | planes |
| coronal plane, anterior or ventral, posterior or dorsal ex. the vertebrae are posterior to the sternum | frontal plane |
| begins with the first contact witht he patient, assess patient's appearance, general behavior, ability to speak clearly and responses to questions. include cognitive status, orientation, memory, level of consciousness, abstract thinking | mental status assessment |
| the ability to execute complex mental processes | cognition |
| ability to cognitively retrieve and report previously stored information | memory |
| lateral plane, lateral and medial, another common medical term is bilateral which refers to both sides of the body ex. the hip is lateral to the sternum | sagittal plane |
| cross-sectional plane, superior or cephalic, inferior or caudal ex. the chest is superior to the abdomen | transverse plane |
| ask to repeat a series of numbers, 3..6..9, say the names of three unrelated objects such as chair, spoon, boat. ask the patient to repeat them. about 5 mis. later ask the patient to recall the three words | immediate memory |
| nurses uses this interview technique to allow the patient a wide range of possible responses e. what did your doctor tell you about your need for hospitalization? | open-ended questions or comments |
| a type of assessment that includes communication of events, comprehending the meaning of events, attentiveness, concentration, demostration of immediate, recent and remote memory, processing information and decision making | cognitive assessment |
| the ability to make judgements and choose between two or more alternatives | decision making |
| refers to person's enduring and prevailing state | mood |
| the ability to make associations or interpretations; like peroverbs ex. the early bird gets the worm. another ex. Don't count your chicken before the're hatched | abstract thinking |
| when the heart contracts and the blood is pumped under high pressure into the aorta and the pulmonary arteries | systole |
| when the blood pressure drops, the ventricles rests and fills, this gives the lowest pressure reading called? | diastole |
| when ventricle contracts the reading will be the highest pressure called? | systole |
| what is the force of blood against the arterial walls. it rises as the ventricles contracts | blood pressure |
| what factors affect respiratory rate | age,exercise,increased altitude,respiratory disease,anemia,anxiety,acute pain (resp. rate up) |
| gradual increase the gradual decrease in depth of respirations followed by a period of apnea | cheyne-stokes respiration |
| periods of no breathing | apnea |
| difficult or labored breathing | dyspnea |
| labored breathing when lying flat but relieved by sitting up | orthopnea |
| more than normal amount of air is entering and leaving the lungs | hyperventilation |
| what do nurses assess with respiratory rate | rate ( tachypnea or bradypnea), depth ( shallow,normal or deep), rhythm( regular or irregular) |
| in clients with chronic lung disease, what signals the brain to increase the rate and depth of ventilation | hypoxemia |
| what could be fatal to a client with chronic lung disease because of their low levels of arterial oxygen that stimulus the client to breath | administering high level of oxygen |
| during a normal, relaxed breath, a person inhales 500 ml of air. this is referred to as? | tidal volume |
| pulmonary respiration that involves movement of air into lungs and out of the lungs | respiration |
| when should the apical be assessed | when the peripheral pulses are irregular, feeble or extremely rapid |
| when should the apical be assessed | before giving medications that can alter heart rate rhythm |
| when should the apical be assessed | when assessing infant's or young children's pulses because their peripheral pulses are deep and difficult to palpate accurately |
| the increased excretion of urine | diuresis |
| events in human that recur at 24 hour intervals | circadian rhythms |
| difference between the apical and radial pulse rate | pulse deficit |
| force of blood against arterial walls | blood pressure |
| use of oral thermometers is contraindicated to the following | infants, patients receiving oxygen therapy, unconscious patients |
| what are the integumentary system | skin, nail, hair and scalp |
| the window to overall health status, provides data to systemic and local problems, largest organ in the body | skin |
| functions of skin | protection, sensation, temperature regulation, excretion & secretion, absorption |
| in what order are the assessment techniques used | interview, inspection, palpation, percussion and auscultation |
| when does ausculation comes second when doing an assessment | when assessing abdominal due to bowel sound |
| fully awake, oriented to person, place and time; responds to all stimuli including verbal commands | Awake and alert |
| is the degree of wakeness or the ability of a person to be aroused | consciousness |
| example of memory that asks about client's birthday, wedding anniversary or place of birth | remote memory |
| example of memory that asks client what they ate for breakfast or who brought them in the hospital | recent memory |
| can identify self and others, identifies correct day, month and year,correct senitive orientationason, current events, and where they are | cognitive orientation |
| the ability to identify person, place, time accurately. also referred to as levels of awareness | cognitive orientation |
| is the resistance to blood flow determined by the tone of the vascular musculature and diameter of blood vessels | peripheral vascular resistance |
| REMEMBER!!!!! healthy arterues have elastiity that allows them to stretch and distend ventricular contraction or systole and recoil back to their original size during ventricular resting or distole | Important to understand |
| number of heart beats in one minute | heart rate |
| amount of blood ejected from left ventricle with one heart beat | stroke volume |
| the volume of blood pumped from the left ventricle throught the circulation in one minute | cardiac output |
| cardiac output formula | CO = SV x HR |
| how do you assess an apical pulse rate? what location and how much? | using stethoscope over apex or tip of the heart between 5th or 6th intercostal space on the L midclavicular line for full minute |
| when do you take the radial and apical pulse simultaneously | when a patient has dysrhytmia |
| the difference between the apical and radial is called | pulse deficity |
| what regulates the involuntary control of respirations | respiratory center in brain stem |
| pulse areas on the neck under sternocleidomastoid muscle | carotid pulse |
| inner aspect of wrist or thumb size | radial pulse |
| pulse behind the knee | popliteal |
| pulse in the inner aspect of the ankle | posterior tibial |
| pulse in the inguinal area | femoral |
| pulse in the anticubital fossa | brachial pulse |
| pulse on the top of the foot between the great and first toe | dorsalis pedis |
| nurses uses this interview technique to allow the patient a wide range of possible responses, encourage free responses, prevents patients from answering only yes or no | open - ended questions |
| ask to repeat three series of numbers 3,6,9...then ask the patient to repeat it after 5 minutes | immediate memory |
| what re areas assessed in the braden scale | sensory, moisture, activity, mobility |
| includes all the pertinent patient information collected by the nurses and other healthcare professionals enabling a comprehensive, effective plan of care to be designed and implemented for the patient | database |
| is a tool used to assess a patient's skin risk for the skin breakdown | braden scale |
| the ability to understand the true nature of one's situation and accept some personal responsibility for the situation | insight |
| diminished visual acuity | presbyopia |
| excess fluid in the tissues may be result of over hydration, heart failure, kidney failure, truma or peripheral vascular disease | edema |
| yellow color of the skin resulting from liver and gall bladder disease, some types of anemia and hemolysis. develops first in the sclera of the eyes and then in the skin and mucous membrane | jaundice |
| a collection of blood in the subcutaneous tissues causing red discoloration | eccymosis |
| approximately 60-70 ml of blood enter the aorta with each ventricular contraction. this is called | stroke volume |
| most commonly assessed parts body to palpate | brachial, apical and carotid pulses |
| most commonly pulse used in an emergency | carotid pulse |
| the number of pulsations in a minute is called | pulse rate |
| the volume of blood pumped by the heart in one minute is called | cardiac output |
| whitish patch areas on the skin, possible cause of depigmentation due to congenital or autoimmune disease | vitiligo |
| paleness of the skin, often results from inadequate amt of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues | pallor |
| the flow of unconnected words that convey no meaning to the listener | word salad |
| gradual increase then gradual decrease in depth of respirations followed by a period of apnea | cheyne stokes respirations |
| periods of no breathing | apnea |
| difficult or labored breathing | dyspnea |
| labored breathing when lying down flat but relieved by sitting up | orthopnea |
| more than normal amt of air is entering and leaving the lungs | hyperventilation |
| during a normal, relaxed breath, a person inhales 500 ml of air. this is referred to as | tidal volume |
| pulmonary ventilation ( breathing) that involves movement of air into lungs ( inspiration) and out of the lungs ( expiration) | respiration |
| cannot be aroused even with use of painful stimuli; may have some reflex activity ( such as gag reflex); | comatose |
| is an standardized assessment tool that assesses level of consciousness | glasgow coma scale |
| what are the parameters that was assessed in the level of consciousness | eye opening, motor response, verbal response |
| validates what the nurse believes is heard and observed | validating questions |
| the conscious and deliberate use of 5 physical senses to gather data information | observation |
| the act of confirming or verifying data | validation |
| type of ulcer with a localized area of tissues necrosis | decubitis ulcer |
| type of ulcer that is caused by the chronic venous insufficiency especially to the leg | venous stasis ulcer |
| an opening in the skin that causes loss od epidermis, dermis and even deeper layers of tissue | ulcer |
| appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patient's name | lethargic |
| unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movement | stuporous |
| is ahigh pitched sound heard on inspiration when there is a narrowing of the upper airway | atridor |
| fine to coarse crackling (ronchi) sounds made as air moves through wet secretions | crackles |
| a position located at the left sternal border and the third intercostal space where both S1 and S2 can be heard | erb's point |
| S1 sound "lub' represents the closing of the mitral and tricuspid valves and is heard over where? | mitral or apical valve |
| S2 sound is dub and can heard where? | aortic and pilmonic valves |
| what kind of edema caused by venous insufficient oxygenation | peripheral edema |
| the period from one heartbeat to the begginning of the next. there are two phases-systole and diatole | cardiac cycle |
| is a collection of subjective data that provide a detailed profile of the patient's health status | health history |
| pu filled, superficial skin such as acne | pustule |
| small elevated solid mass such as a mole. <0.5 cm | papule |
| group of coalesced papules .0.5 cm | plaque |
| area is raised and red | macular papular rash |
| the ability to focus on a specific stimilus | concentration |
| what are the signs of normal pupils | black, round, regular equal in size 93-7mm) and iris clearly visible |
| what is PERRlA, used when assessment of pupillary reaction is normal in all tests | pupils equal round and reactive to light and accomodation |
| is a type of rapid focused assessment conducted to determine potentially fatal situations like assessing airway | emergency assessment |
| the examination of patient for objective data that may better define the patient's condition and help the nurse in planning care | physical assessment |
| cloudy pupils indicate what | cataracts |
| dilated pupils indicates what type of eye disease | glacauma, trauma, neurological disorders, eye medications, withdrawal from opioids |
| constricted pupils indicate what type of problem | inflammation of the iris or opioid intoxication |
| type of sensation in order to determine cutaneous sensory function. ability to determine cold vs. warm, rough vs smooth | tactile sensation |
| excessive perspiration which can be related to fever, exercise, anxiety, cardiac or respiratory problems or obesity | diaphoresis |
| adequacy of blood flow through the small vessels of the extremities to maintain tissue function | peripheral tissue perfussion |
| specimen drawn from an artery that provides information about PaO2 and PaCO2 and acid base balance | Arterial Blood Gases |
| non invasive technique that measures the oxygen saturation (spo20 of arterial blood. Normal is 95% or greater | pulse oximetry |
| made by air passing through moisture in small air passages and alveoli | fine crackles |
| when they are made by air passing through moisture in the bronchules, bronchi and trachi, also called ronchi | coarse crackles |
| irregular, superficial area of skin edema/hives. it may be often be a result of an allergic reaction | wheal |
| begins with the first contact with the patient. assess patient's appearance, general behavior, ability to speak clearly and responses to questions. include cognitive status, orientation, memory , level of consciousness, abstract thinking, mood | mental health status |
| describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction | pulse amplitude |
| how to assess pulse amplitude | palpating the flow of blood through an artery |
| elevated, encapsulated lesion in the dermis or subcutaneous layer filled with liquid or semi-solid material. it is deeper and don't involve the epidermal area | cyst |
| is the preferred term used when documenting scab | crusting |
| is the correct way to describe a wound that contains pus | purulent drainage |
| large, fluid filled elevation like a burn | bulla |
| large flat non palpable change in skin color | patch |
| purple discoloration | purpera |
| medium elevated solid mass such as wart | nodule |
| fluid filled elevation ,0.5cm, small superficial skin elevation like herpes, chicken pox, shingles | vesicle |
| large elevated mass | tumor |
| sitting up at a 45 degree angle | semi fowler's position |
| sitting up at a 90 degree angle, promotes greatest lung expansion | high fowlers position |
| alteration in the angle between the nail and its base that is caused by the chronic lack of oxygenation. often sees in patient with COPD and emphysema | nail clubbing |
| soft, low pitched sounds auscultated over the lung periphery or base | vesicular breath sound |
| bronchial or tubular breath sounds are heard over | trachea |
| can be heard over trachea, high pitched expiration longer than inspiration | bronchial sounds |
| moderate blowing, inspiration is equal to expiration and can be heard over mainstem broncus | broncho vesicular sound |
| soft, low pitch sounds heard over base during inspiration, which is longer than expirations | vesicular sound |
| is a harsh high pitched sound on inspiration when there is a narrowing of the upper airway such as the larynx or trachea | stridor |
| describes as noisy, strtonous respirations | stertorous breathing |
| continous sound that originate in small air passages that are narrowed by secretions, swelling or tumors and may be inspiratory or expiratory and are high pitch sound | wheezes |
| are not normally heard in the lungs, if present, maybe ausculatated along with normal breath sounds | adventitious breath sounds |
| how to palpate respiratory excursion | place hand in T9 or T10. normal separation is when thumbs separate 1.5-2 inches or 3.5 cm. instruct to take a deep breath |
| faintly perceptible vibrations felt through the chestwall when the client speaks commonly ask to say "99" | tactile fremitus |
| 2nd intercostal space , left upper sternal border | pulmonary valve |
| 2nd intercostal space, right upper sternal border | aortic valve |
| fifth intercostal space, medial to left midclavicular line | mitral valve or apical |
| 4th intercostal space, lower left sternal border | tricuspid valve |
| core body temperature well below normal, usually caused by exposure to extreme cold | hypothermia |
| core body temperature well above normal, usually caused by exposure to extreme heat | hyperthermia |
| body temperature above normal, usually caused by infection or response to tissue injury | febrile, fever, pyrexia |
| when assessing moisture, what physiologic changes of aging can worsen existing skin condition | dryness |
| looks like eccymosis except it elevates the skin and looks like a swelling | hematoma |
| balding or loss of hair which can be cause of radiation therapy, cancer treatments, infection, malnutrition or hormone disorder | alopecia |
| excess body hair on the face, chest and abdomen, arm and legs. occurs in females and may be due to endocrine or metabolic dysfunction | hisutism |
| normal rectal and tympanic temp, which are the core temperature | 99.5 |
| normal oral temp | 98.6 |
| normal axillary temp | 97.6 |
| normal heart rate | 60-100 beats/minute |
| pulse higher than 100 | tachycardia |
| pulse lower than 60 | bradycardia |
| normal respiration rate | 12-20 breaths/min |
| respiration higher than 20 | tachypnea |
| respiration lower than 12 | bradypnea |
| normal bp | 120/80 mmHg |
| heat production primarily caused by | metabolish |
| without fever, normal body temp | afebrile |
| body temp is controlled by the thermoregulatory system in the | hypothalamus |
| the patient may sit upright in a chair or in the side of the examining table or bed. Allows visualization of the upper body and facilitate lung expansion. used to take vital signs and assess head, neck,posterior/anterior thorax and lungs, breasts, heart | sitting position |
| the patient is in the dorsal recumbent position with the buttocks at the edge of examining table and feet supported in stirups. this position is used to assess the female rectum and genetalia | lithotomy position |
| the patient kneels, using the knees and chect to bear the weight of the body. the position is used to assess the rectal area | knees-chest position |
| the patient lies on the abdomen, flat on the bed with the head turned to one side. this position is used to assessed the hip joint and posterior thorax | prone position |
| excessive amount and rate of speech composed of fragmented or unrelated ideas | flight ideas |
| a fixed false belief not based in reality | delusion |
| a client eventually answers the questions but only after giving excessive unnecessary detail | circumstantial thinking |
| a delusional belief that others can hear or know what the client is thinking | thought broadcasting |
| stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea | thought blocking |
| rapid fluctuating or changing mood | labile |
| lack of emotional response, lack of change in facial expression and flat voice tones | flat affect |
| usually conducted when a patient first enters a healthcare setting, with information providing a baseline for aomparing later assessment | comprehensive assessment |
| is the act of listening with a stethoscope to sounds produce within the body. It is performed by placing the stethoscope diap\hragm or bell against the body part being assessed | auscultation |
| act of stiking one object aginst another to produce sound. | percussion |
| client's inaccurate interpretation that general events are personally directed to him/her such as hearing a speech on the news and believing the message had personal meaning | ideas of reference |
| showing little or slow to respond facial expression | blunted affect |
| displaying facial expression that is congruent with mood or situation; often silly or giddy regardless of cicumstances | inappropriate affect |
| displaying one type of expression usually serious or somber | restricted affect |
| displaying a full range of emotional expressions | broad affect |
| the gathering of data about a specific problem that has already indentified | focused assessement |
| may result in the skin returning to its normal position slowly. this is when skin turgor is described poor | dehydration |
| is the fullness or elasticity of the skin and is usually assess on the sternum or under the clavicle | skin turgor |
| are small, red blood spots caused by capillary bleeding | petechiae |
| the patient lies flat on the back with legs together but extended and slightly bent at the kneew. this positionis used to assess the head, neck, anterior thorax, and lungs, breasts, heart, abdomen, extremities and peripheral pulses | supine position |
| the patient lies on the back with legs separated, knees bent and the soles of the feet flat on the bed. this position id used to assess the head,neck, anterior thorax and lungs, breasts, heart, extremeties and peripheral pulses | dorsal recumbent position |
| the patient lies on the left or right with the lower arm behind the body and the upper arm bent at the shoulder and elbow. the knees are net with the upper most leg at a more acute angle. | sim's position |
| small, flat change in skin color such as freckle | macule |
| limited cjoices of response may be yes or no. used to gather specific information to focus on a particular area | closed ended questions |
| are small, red blood spots caused by capilllary bleeding | petechiaea |
| planned communication to obtain patient data | interview |
| maybe used by nurses to help patient indentify potential and actual health risks and to explore the habits, behaviors, beliefs, attitudes, and values that influence their health | nursing history |
| compares a patient's current status to baseline data obtained earlier | time lapse assessment |
| is an assessment technique that uses the sense of touch. the hands and fingers are sensitive tools and can assess temperature, turgor, texture, moisture, vibration and shape | palpation |
| is the process of performing deliberate, purposeful observations in a systematic manner. the nurses observes visually, but aloso uses hearing and smell to gather data throught out the assessment | inspection |
| invented words that have meaning only for the client | neulogism |
| maintenance of posture or position over time even when it is awkward or uncomfortable | waxy flexibility |
| overall slowed movements | psychomotor retardation |
| repeated purpisely behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair or tapping the foot | automatisms |
| a type of personality tests that are unstructured and usually conducted by the interview method. stimuli for this tests such as pictures or rorschach's ink blot are standard | projective tests |
| a type of psychological tests that reflects the client's personality in self-concept, impulse control, reality testing and major defenses | personality tests |
| a typr of psychological tests that are designed to evaluate the client's cognitive abilities and intellectual functioning | intelligence tests |
| involves thinking about the overall assessment rather than focusing on isolated bits of information. leads to the formulation of nursing diagnoses as a bases for the client's plan of care | data analysis |
| is the way one views oneself in terms of personal worth and dignity | self-concept |
| wandering off the topic and never providing the information requested | tangential thinking |
| ability to acquire, organize and use information | information processing |
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