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HA Part II
HA EXAM 1
| Question | Answer |
|---|---|
| Have a client occlude the tragus of one ear.Whisper a 2 syllable word 1-2 feet behind the client the repeat this with the other ear. | Whisper Test |
| use tuning fork placed on the center of the head or forehead. Ask whether the client hears the sound better in one ear or the same in both ears. | Weber Test |
| use tuning fork and place at the base on the client's mastoid process.When the client no longer hears the sound, note the time interval and move it in front of the external ear. When the cient no longer hears the sound, note the time interval. | Rinne Test |
| Pupils Equal, Round, Reactive to Light and Accommodation | PERRLA |
| Pupillary Rxn to light: Darken room, have client focus on a distant object, shine light obliquely into the pupil and observe the pupil's rxn to light. Normally, pupils constrict | PERRLA |
| shifting gaze from far to near (use a pin move it closer to the nose). Normally, pupils constrict and converge. | Accommodation |
| Normal is 20/20. The top # stays the same, the bottom indic the distance that you can see the chart at. 20/30 means you can see at 20 feet what others can see at 30 feet (20 is constant because you are stationary) | Snellen Charts |
| Cancer is most commonly found in the Axillary Tail of Spencein where? | Breast |
| Upper outer quadrant (R/L), Lower outer quadrant (R/L), Lower inner quadrant (R/L), Upper inner quadrant (R/L) | Breast |
| Gender,age,genetics,early or late menopause,no natural kids,first kid after 30,oral contraceptives,alcohol usage,breast irradation,hormone replacement,wet ear wax,smoking,radiation to chest as a child | Breast Cancer Risk Factors |
| supernumerary nipples, fixation, edema, mastitis, nippled discharge, | Abnormal findings in female breasts |
| gynecomatia, carcinoma | abnormal findings in male breasts |
| Prebycusis common after 50 yrs. Negative self-image with hearing aid,elongated earlobes with linear wrinkles, harder,cerumen builds as cilia in ear canal become more rigid, coarse,thick wire-like hair may grow at ear canalentrance eardrum appears cloudy | Ears of the elderly |
| decrease in size, decrease in firmness, glandular tissue decreases whereas fatty tissue increases | Breast of the elderly |
| Gums recede,ischemic and undergo fibrotic changes,tooth surfaces worn down,decr ability to smell and taste. Oral Mucosa drier and more fragile. Varicose veins ventral surface of tongue. | Mouth of the elderly |
| pale, lesions, dry, loss of turgor | Skin of the elderly |
| thinner | Hair of the elderly |
| thickened, yellow, brittle | Nails of the elderly |
| pain and decr range of motion,facial wrinkles,lower face shrink and the mouth may be drawn inward, pulsation of temporal artery decr,cervical curvature incr,decr flexion,extension,lateral bending,rotation of the neck,thyroid more nodular or irregular. | Neck of the elderly |
| high harsh or hollow Loud short during inspiration,long in expiration trachea and thorax | BRONCHIAL |
| moderate mixed moderate same during inspiration and expiration located over the major bronchi-posterior between scapulae;anterior:around the upper sternum in the first and second intercostal spaces | Bronchovesicular |
| low breezy soft long in inspiration,short in expiration located in peripheral lung fields | Vesicular |
| Cranial Nerve I: "God gave us 1 nose." Smell. Test:have client occlude one nostril w/finger.Ask client to identify nonirritating and familiar odors.Repeat test w/other nostril. | Olfactory nerve I |
| Cranial Nerve II: "God gave us 2 eyes." Vision. Test: assess w/Snellen chart and perform an opthalmoscopic exam.Chk peripheral vision by confrontation and chk color vision. | Optic nerve II |
| Cranial Nerve III:"3,4,6 makes my eyes do tricks!" Motor.Contr pupilary constrctn,upper eyelid mvmnt& most eye mvmnt.Tested with IV and VI.Inspect eyelid for ptosis(drooping),assess ocular mvmnts¬e deviatns.Test accomm&direct consensual light reflexes. | Oculomotor Nerve III |
| Cranial Nerve IV:"3,4,6 makes my eyes do tricks!" Motor.Contr downward&inward eye mvmnt.Tested w/3&6.Inspect eyelids for drooping,assess ocular mvmnts and note any eye deviation.Test accomm, direct and consensual light reflexes. | Trochlear Nerve IV |
| Cranial Nerve VI:"3,4,6 makes my eyes do tricks!"Motor.Controls lateral eye movement.Tested w/3&4.Inspect eyelids for drooping,assess ocular mvmnts and note any eye deviation.Test accomm,direct and consensual light reflexes. | Abducens Nerve VI |
| Cranial Nerve V:"TRI"Sensory and Motor.Contr sensation in the cornea,nasal & oral mucosa,& facial skin,and chewing.Test:Ask client to clench teeth&assess the chewing musc then try to open the clients jaws after asking client to keep them tightly closed. | Trigeminal Nerve V |
| If client is alert&blinking normally the cotton wisp test does not need to be done.Touch the cornea w/the cotton wisp.Sensory:tell client to close their eyes and lightly touching the forehead,cheeks,chin, then noting if they felt equally on both sides | Trigeminal Nerve V |
| Cranial Nerve VII:"Across face." Sensory&Motor.Contr mvmnt of face and taste.Test:taste percep on the anterior 2/3 of tongue;salty&sweet.Have the client smile,frown,show teeth.Ask client to close eyes against resistance. | Facial Nerve VII |
| Cranial Nerve VIII:"Fits nicely in your ear."Contr hearing&vestib funxn,sensory.Hearing Testing the cochlear portion,acuity tests.Equilibrium Testing:vestibular portion. Ex:swaying when standing or walking. Weber or Rinne Test. | Acoustic Nerve VIII |
| Cranial Nerve IX:(9&10 Under my chin.)Sensory&Motor.Contr abil to swallow,sensatn in soft palate,tonsillar mucosa,taste percep on posterior 1/3 of tongue&salivatn.Client should taste bitter/sour.Client says aah,watch symm elev of soft palate.Gag reflex. | Glossopharyngeal Nerve IX |
| Cranial Nerve X:("9&10 Under my chin.")Sensory&Motor.Contr swallowing&phonation,sens in ext ear posterial wall,sens behind ear.Contr sens in thoracic & abdominal viscera. Tested with Cranial Nerve IV. | VAGUS NERVE X |
| Cranial Nerve XI:"Shrug shoulders." Motor,contr neck and shoulder musc.Palpate and inspect the sternocleidomastoid muscle as the client pushes the chin against the nurses hand.Next the test the trap musc.client shrugs shoul against the nurse's hands | Spinal Accessory Nerve XI |
| "Stick out your tongue."Motor.Contr tongue mvmnt invol in swallowing&speech.Obs tongue for asymmetry,atrophy,deviation to 1side,&uncomf twitching.Ask client to push the tongue against a tongue depressor,then have client move tongue fast in&out,side-side. | Hypoglossal Nerve XII |
| cond in which the thyroid gland makes too much thyroid hormone.Often called "overactive thyroid."thyroid releases too much of its hormones over a short(acute)/long (chronic)per of time.Many diseases can cause this. | Hyperthyroidism |
| MANY diseases and cond can cause this problem, inclu:Getting too much iodine.Graves disease (accounts for most cases.Inflammation (thyroiditis) of the thyroid due to viral infections or other causes.Noncancerous growths of the thyroid gland or pituitary g | Hyperthyroidism |
| swelling in the anterior neck,weight loss,excessive perspiration,hungry all the time,slightly enlarged thyroid,bruit heard during thyroid ascultation. | Hyperthyroidism |
| a collapsed or airless state of the lung that may be the result of airway obstruction caused by accum secretions or failure of client to deep breathe or ambulate about after surgery;a post-op complication that usually occurs 1-2days after surgery. | Atelectasis |
| Beau's lines (acute illness),Spoon nails (deficiency anemia),Early clubbing (oxygen deficiency), pitting (Psoriasis),Late clubbing (oxygen deficiency),Paronychia (local infec) | Common Nail Disorders |
| trachea pulled to one side in cases of tumors,thyroid gland enlargement,aortic aneurysm,pneumothorax,atelectasis,or fibrosis. Coarse tissue,irrugular consistency may indicate an inflamm process. A soft,blowing,swishing sound auscultated over thyroid. | Abnormalities of the neck |
| Asymmetry,Border,Color,Diameter,Elevation! Used in identification of skin cancer. | ABCDE of skin assessment |
| normally are palpable,round,smaller than 1cm,imp to assess size,shape, position ,mobility,consistency,tenderness and locale. | Normal lymph nodes |
| nodes in front of ear | preauricular nodes |
| nodes behind the ear | postauricular nodes |
| nodes at posterior base of the skull | Occipital nodes |
| nodes on the medial border of the mandible | submandibular nodes |
| nodes at the angle of the mandible on the front edge of the sternomastoid muscle | tonsillar nodes |
| nodes a few cm behind the tip of the mandible | submental nodes |
| enlargement,tenderness,swelling,immobility,hard and nontender on the left side may indic metastasis from malignancy in the abdomen or thorax! | Abnormalities of Lymph Nodes |
| noninvasive test that registers the Oxy sat of the client's hemoglobin.The capillary Oxy Sat is meas as a %.Norm Val 96-100%.Read can alert nurse to hypoxemia b4 clin signs occur.sensor is put on clients finger,toe,nose,earlobe,forehead to meas oxy sat. | Pulse Oximetry |
| H:How torelease info to the healthcare workers that "NEED TO KNOW." | H in HIPAA |
| I: Impermissible uses and disclosures resulting in lawsuits. | I in HIPAA |
| P: Protect privacy of individual identifiable healthcare information. | P in HIPAA |
| A: Arrange for sharing information with family in a discrete manner. | A in HIPAA |
| A: Access by client to medical records, including the right to see and copy! | A in HIPAA |
| Nurse needs: Sphyg,steth,thermometer (oral, tymp,rectal,elec),watch w/2nd hand,pain rating scale | Equipment needed for VITAL signs |
| obtain temp, PR, RR, papitate radial pulse and pump BP cuff until you can no longer feel the radial pulse,then auscultate brachial artery with steth,pump cuff 30mm Hg over,obtain sys and dia data | Getting a patients BP and Vitals |
| small cup of water to aid in swallowing | head and neck exam |
| ruler with cm markings,magnifying glass,woods light | skin,hair,nails exam |
| penlight,Snellen chart,Opthamaloscope,cover card | eye exam |
| otoscope,tuning fork | ear exam |
| penight,tongue depressor | mouth,throat,nose and sinus exam |
| stath (diaphragm),markingpencil, cm ruler | thorax and lung exam |
| steth (bell&diaphragm) and two cm rulers | heart and neck exam |
| describe the sign or symptom. Feeling,appearance,sound,smell, or taste. | Character (C in COLDSPA) |
| When did it begin? | Onset (O in COLDSPA) |
| Where is it? Does it radiate? Does it occure amywhere else? | Location (L in COLDSPA) |
| How long does it last? Does it recur? | Duration (D in COLDSPA) |
| How bad is it? How much does it bother you? | Severity (S in COLDSPA) |
| What other symptoms occur with it? How does it affect you? | Associated factors/Affects on client (A in COLDSPA) |
| hands-on physical exam. non-invasive.common.physical assessment.prov data that reflect the status of several body sys inclu:cardiovasc,neuro,periph vas,resp sys. | Vital Signs |
| 96-99.9 F orally, 95-98 F (Axillary), 97-100 F (Rectal),lowest in the AM and highest in the late evening (8pm-12am). Old Folks are 95-97.5 F.Above 100 or below 96 is abnormal! | Temperature |
| shock wave produced when the heart contracts and forcefully pumps blood out if the ventricles into the aorta. The shock wave travels along the fibers of the arteries and is commonly called arterial or peripheral what? | Pulse |
| gives a a good picture of the clients overall health. Assess rate, rhythm,amplitude,contour,elasticity...thready/weak,Normal,Bounding.If an abnormality is assessed further assessment should be performed! | Radial Pulse |
| can be easily observed w/out alerting the client by watching the chest rise and fall b4 removing the steth after you have completed the apical beat. | Respirations |
| pressure exerted on walls of the arteries.Varies with cardiac cycle, reaching a high point w/systole and a low point w/diastole.A pressure of blood in arteries when ventricles are contracted(sys)and when ventricles are relaxed(dia).Expressed ay sys/dia. | Blood pressure (BP) |
| BP increases with increased______and decreases with decreased_____. | Cariac Output |
| BP increases when more effort is required to push blood through stiffened arteries. | Distensibility of the arteries |
| BP increases with increased_______ and decreases with decreased ______. | Blood volume |
| BP increases when blood flow is slowed due to resistance and decreases when blood flow meets no resistance. | Blood velocity |
| BP increases when the blood is thickened and decreases with thinning of the blood. | Blood viscosity |
| the difference between systolic and diastolic pressure | Pulse Pressure |
| screening for this is very imp in devel a comprehensive plan of care for patient.its essential to assess for__during the initial assessment.when __is present it is imp to identify the location,intensity,quality,duration,alleviating or aggravating factors. | PAIN |
| intensity measurement tool. 1-10 Likert scale. Quality of ___may be described using COLDSPA. | Pain assessment |
| when ____ and ____ are abnormal, they should be further assessed,further explored, re-assessed at a later time,decided by the nurse.Also referal to the client's promary care physician. | Vital signs and Pain |
| an unpleasant sensory and emotional experience, which we primarily assoc w/tissue damage.Explained as a combo of physiological phenomena but with psychosocial aspects that influence perception of the ___."___ is what every person says it is!" | Pain |
| pain perceived at the source and extending to other tissues | Radiating |
| pain perceived in body areas away from pain source | Referred |
| pain that causes an abnormal processing of pain msgs and results from past damage to peripheral or central nerves due to sustained neurochemical levels. | Neuropathic pain |
| pain with high resistance to pain relief | Intractable Pain |
| lying flat on your back | Supine position |
| lying face down (arms may be positioned internally or externally) | Prone position |
| side-lying position. prevents pain and bleeding. | Lateral position(Lateral Recumbent) |
| forward side-lying position | Sims' or semi-prone position |
| lying on right side. Prevents pain and bleeding. | Right Lateral Recumbent position |
| lying on left side. prevents pain and bleeding. | Left Lateral Recumbent position |
| positioning client with the head of the bed 30 degrees, reduces swelling and edema in neck area. | Semi-Fowler's position |
| a person sitting straight up or leaning SLIGHTLY back (45 degrees). Legs may be straight or bent.Reduces swelling and edema in neck area. | Fowler's position |
| a person lying supine with their head slightly lower than their feet | Trendelenberg Position |
| lying flat or your back with your legs in stirrups. | Lithotomy Position |
| a person lying supine (flat on back) with their feet slightly lower than their head.Prescribed to promote gastric emptying and prevent esophagul reflex. | Reverse Trendelenberg Position |
| people sit in this position with their hands on their knees and their elbows out,leaning fwd. they do this bc theyre short of breath and struggling to get enough air.This position should worry you. | Tripod position or tripoding |
| A patient sittingin the ____position with their legs crossed is usually not in any distress. A patient is sitting upright. | High Fowler's |
Created by:
boomer_bevo
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