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Questions and Answers
What is the term for an elevated, pus-filled area on the skin?
What is the term for an elevated, pus-filled area on the skin?
Which of the following describes a papule?
Which of the following describes a papule?
Which condition is characterized by purple spots larger than petechiae?
Which condition is characterized by purple spots larger than petechiae?
What skin condition is caused by excessive rubbing, leading to thick, leathery patches?
What skin condition is caused by excessive rubbing, leading to thick, leathery patches?
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What is a raised palpable mass that extends deeply into the dermis and is larger than 1 cm called?
What is a raised palpable mass that extends deeply into the dermis and is larger than 1 cm called?
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Which skin lesion typically occurs in premature infants and resembles fine hair?
Which skin lesion typically occurs in premature infants and resembles fine hair?
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What is characterized as a localized collection of clotted blood within an organ or tissue?
What is characterized as a localized collection of clotted blood within an organ or tissue?
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What describes the condition of having soft, spoon-shaped nails potentially caused by anemia?
What describes the condition of having soft, spoon-shaped nails potentially caused by anemia?
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What does a slow capillary refill time of more than 2 seconds indicate?
What does a slow capillary refill time of more than 2 seconds indicate?
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Which condition is characterized by nonblanchable erythema of intact skin?
Which condition is characterized by nonblanchable erythema of intact skin?
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What are the characteristics used to assess lymph nodes?
What are the characteristics used to assess lymph nodes?
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What is a key symptom of a tension headache?
What is a key symptom of a tension headache?
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Which of the following is a sign of clubbing in the nails?
Which of the following is a sign of clubbing in the nails?
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What is the significance of half and half nails in nail abnormalities?
What is the significance of half and half nails in nail abnormalities?
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Which type of headache is likely to be accompanied by tearing or redness of the eye?
Which type of headache is likely to be accompanied by tearing or redness of the eye?
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What nail abnormality is known as koilonychia?
What nail abnormality is known as koilonychia?
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What is the procedure for assessing distant visual acuity using a Snellen chart?
What is the procedure for assessing distant visual acuity using a Snellen chart?
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Which of the following assessments checks for nystagmus?
Which of the following assessments checks for nystagmus?
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Which factor is NOT a risk factor for eye illnesses or injuries?
Which factor is NOT a risk factor for eye illnesses or injuries?
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What is the primary purpose of the whisper test?
What is the primary purpose of the whisper test?
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Which examination requires inspecting the tympanic membrane?
Which examination requires inspecting the tympanic membrane?
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What should a nurse educate a patient about to help prevent traumatic brain injuries?
What should a nurse educate a patient about to help prevent traumatic brain injuries?
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How is the Rinne test conducted?
How is the Rinne test conducted?
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Which of the following assessments can help evaluate the ability to maintain balance?
Which of the following assessments can help evaluate the ability to maintain balance?
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What is a crucial step for nurses when preparing an adult for a physical examination after abuse?
What is a crucial step for nurses when preparing an adult for a physical examination after abuse?
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What type of equipment is necessary for a general physical examination of an abuse victim?
What type of equipment is necessary for a general physical examination of an abuse victim?
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What should be prioritized when examining a client suspected of being abused?
What should be prioritized when examining a client suspected of being abused?
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When is the HITS Assessment Tool typically utilized?
When is the HITS Assessment Tool typically utilized?
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What additional action may be required if sexual assault is confirmed?
What additional action may be required if sexual assault is confirmed?
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How should a nurse approach a physical examination if intimate partner violence is suspected?
How should a nurse approach a physical examination if intimate partner violence is suspected?
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What screening guideline should be followed in healthcare settings?
What screening guideline should be followed in healthcare settings?
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What should be done if physical evidence of abuse is found during an examination?
What should be done if physical evidence of abuse is found during an examination?
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What is indicated by drooping of the upper eyelid?
What is indicated by drooping of the upper eyelid?
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What is the correct term for a small, usually painless lump on the edge of the eyelid caused by a blockage of a gland?
What is the correct term for a small, usually painless lump on the edge of the eyelid caused by a blockage of a gland?
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What condition is characterized by redness of the sclera due to infection, irritation, or an allergic reaction?
What condition is characterized by redness of the sclera due to infection, irritation, or an allergic reaction?
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What term describes a condition in which there is an inward turning lower eyelid, possibly causing irritation to the eye?
What term describes a condition in which there is an inward turning lower eyelid, possibly causing irritation to the eye?
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What is the common name for the condition caused by a self-limiting inflammation of the episclera?
What is the common name for the condition caused by a self-limiting inflammation of the episclera?
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What condition may be indicated by the presence of broken tiny capillaries on the sclera due to actions like coughing or sneezing?
What condition may be indicated by the presence of broken tiny capillaries on the sclera due to actions like coughing or sneezing?
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Which test distinguishes between conductive and sensorineural hearing loss using a tuning fork placed on the head?
Which test distinguishes between conductive and sensorineural hearing loss using a tuning fork placed on the head?
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What does equal-sized pupils indicate when examined, despite being potentially benign?
What does equal-sized pupils indicate when examined, despite being potentially benign?
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Study Notes
Assessment of Abuse
- Preparing Adult for Physical Examination After Abuse: Consider the specific injuries and consult a Sexual Assault Nurse Examiner (SANE) for rape cases.
- Equipment Needed for Physical Examination for abuse: Vital sign measuring equipment is necessary. Additional equipment depends on the specific injuries.
- Key Points for Examining a Client Suspected of Abuse: Ensure privacy, keep hands warm, remain nonjudgmental, and educate the client about potential risks and available support.
- HITS Assessment Tool: Use when time is limited to quickly assess potential abuse.
- Additional Assessments for Sexual Assault: A gynecologic exam may be needed, usually conducted by a SANE.
- Approaching Physical Examination for Intimate Partner Violence (IPV): Follow standard procedures for the affected body system while ensuring the client feels comfortable. Encourage them to remove all clothing and wear a gown for a full-body assessment.
- General Screening Guidelines for Abuse: Be alert for signs of domestic violence during interviews and examinations. Use appropriate tools like the Abuse Assessment Screen for at-risk clients.
- Handling Physical Evidence of Abuse: Take digital photographs with the client's consent, adhering to the healthcare facility or agency policy.
- Analyzing Data to Make Clinical Judgments: Identify abnormal findings and client strengths after gathering subjective and objective data. Cluster the data to reveal patterns informing clinical judgments regarding family violence.
Skin Lesions
- Wheal: Elevated mass with a transient border, often irregular in shape and size (rash).
- Pustule: Elevated, pus-filled area on the skin.
- Papule: Raised, palpable solid mass with a circumscribed border less than 0.5 cm (example: wart).
- Macule: Flat, nonpalpable changes in skin color.
- Plaque: Raised, palpable solid mass greater than 0.5 cm (example: psoriasis).
- Nodule: Elevated, solid, palpable mass that extends deep into the dermis, less than 1 cm.
- Tumor: Elevated, solid, palpable mass that extends deep into the dermis, greater than 1 cm.
- Vesicle: Elevated, palpable fluid-filled mass less than 0.5 cm (example: varicella).
- Bulla: Elevated, palpable fluid-filled mass greater than 1 cm (example: large 2nd-degree burn blisters).
- Cyst: Elevated, encapsulated, fluid-filled or semisolid mass originating in subcutaneous tissue or dermis, usually 1 cm or larger.
- Secondary Skin Lesions: Erosions, scars, ulcers, fissures, lichenification.
- Lichenification: Caused by excessive rubbing, resulting in leathery, thick patches of skin.
- Vascular Skin Lesions: Contusion, ecchymosis, purpura, petechiae, hematoma, hemorrhage, cherry angioma, spider angioma, telangiectasias.
- Ecchymosis: Purple area, non-elevated, hemorrhagic area on skin, larger than petechiae.
- Hematoma: Localized collection of clotted blood in an organ, body cavity, or tissue caused by broken blood vessels.
- Hemorrhage: Large amount of bleeding.
- Petechiae: Pinpoint, non-raised round purple spots less than 3 mm caused by small vessels leaking blood under the skin. May be caused by disseminated intravascular coagulation (DIC) or sepsis.
- Purpura: Purple spots, non-raised, larger than petechiae greater than 3 mm caused by small vessels leaking blood under the skin.
- Cherry Angioma: Small, round, red, raised skin growth on the trunk or extremities, common in the elderly.
- Lanugo: Fine hair covering a newborn, especially in premature infants.
- Alopecia: Areas of patchy hair loss or baldness caused by the immune system attacking hair follicles.
- Hirsutism: Excessive facial hair growth in a female.
- Clubbing: Wide, spoon-appearing nails with an angle greater than 180 degrees, caused by chronic hypoxia.
- Koilonychia: Soft, spoon-shaped nails, caused by anemia, endocrine, cardiac, or liver disease.
- Yellow Nail Syndrome: Hard, yellow nails, may be caused by respiratory disease, lymphedema, or AIDS.
Eye Assessment
- Accommodation of Pupils: As an object moves closer, pupils constrict, and eyes converge.
- Cover Test: Looking straight ahead, cover one eye and observe the uncovered eye. Remove the cover, and the eyes should remain fixed and not move or drift.
- Nystagmus: Eye shakes during the cardinal positions test of cranial nerves III, IV, and VI.
- Conjunctivitis: General redness of the white (sclera) of the eye, caused by infection, irritation, or allergic reaction.
- Ptosis: Drooping of the upper eyelid, may be caused by nerve damage or myasthenia gravis.
- Ectropion: Everted (sags out) lower eyelid. Can cause exposure and drying of the eye.
- Chalazion: Small, usually painless lump on the edge of the eyelid, caused by blockage of the gland at the base of an eyelash.
- Hordeolum: Infection of a gland in the eyelid.
- Entropion: Inward turning lower eyelid, may cause irritation of the eye.
- Blepharitis: Staff infection of the eyelid.
- Diffuse Episcleritis: Self-limiting inflammation of the episclera (thin layer of tissue between conjunctiva and sclera) of the eye.
- Conjunctival Hemorrhage: Caused by coughing, sneezing, or childbirth; broken tiny capillaries on the sclera.
- Miosis: Pinpoint pupils caused by narcotics or brain damage.
- Anisocoria: Unequal pupils, may be benign or caused by ocular or parasympathetic nerve damage.
- Mydriasis: Dilated, fixed pupils, caused by anesthesia, shock, or CNS dysfunction.
Ear Assessment
- Conductive Hearing Loss: Mechanical problem in the outer or inner ear that causes hearing loss.
- Sensorineural Hearing Loss: Injury, disease, or congenital nerve damage in the inner ear causes permanent hearing loss.
- Weber Test: Distinguishes between conductive and sensorineural hearing loss. Tuning fork placed on the top of the head to assess if the sound is unilateral and symmetrical. Conductive loss: hear sound in the bad ear. Sensorineural loss: hear sound in the good ear.
- Rinne Test: Hearing test to compare air to bone conduction. AC should be greater than BC. Conductive hearing loss: BC > AC.
- Romberg Test: Assesses for vertigo. Close eyes standing with feet together and observe for swaying.
- Otitis Externa: Infection of the outer ear canal.
- Exostosis: Bone growth in ear canal that can narrow and obstruct the eardrum.
- Microtia: Abnormally formed small pinna linked to congenital disorders.
- Tophi: Uric acid crystal buildup on the pinna, related to gout.
Nail Assessment
- Abnormalities in Nails: Dirty, broken, poor hygiene (a sign of job or hobby), cyanosis (anemia), hemorrhage (trauma), discoloration (infection/psoriasis), pitting (psoriasis), clubbing (hypoxia), spoon nails (iron deficiency), thick nails (decreased circulation/onychomycosis), paronychia (infection), ridging, half and half, koilonychia, yellow nails
General Assessment
- Capillary Refill: Indicates status of peripheral circulation. Slow capillary refill (+2 seconds) is a sign of respiratory or cardiac problems that cause hypoxia.
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Pressure Ulcers:
- Stage I: Nonblanchable erythema of intact skin.
- Stage II: Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed.
- Stage III: Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon.
- Stage IV: Full-thickness skin loss with damage to bone, muscle, or underlying tissues.
- Lymph Nodes: Nonpalpable, small, bead-like, non-tender, mobile.
- Palpation of Lymph Nodes: Assess size, shape, delimitation, mobility, consistency, tenderness.
- Lymph Node Names: Preauricular, postauricular, tonsillar, occipital, submandibular, submental, superficial cervical, posterior cervical, deep cervical.
- Neck Assessment: Assess position, symmetry, lumps, masses, swelling. Palpate thyroid cartilage and cricoid cartilage (move up), cervical vertebra palpable, ROM, and trachea in midline.
- Palpation of TMJ: Assess for swelling, tenderness, crepitation, and ROM.
Headache Types
- Tension Headache: Dull, tight, diffuse pain in the frontal, temporal, and occipital region.
- Migraine Headache: Unilateral and travels, often with nausea and vomiting, sensitivity to light and sound. More common in women.
- Cluster Headache: Stabbing pain, may be accompanied by tearing, eyelid drooping, reddened eye, or runny nose. Located around the eye and orbit. More common in men.
- Sinus Headache: Deep, constant throbbing pain, often moderate to severe, occurs after a cold, localized to one area of the face.
Visual Acuity Assessment
- Snellen Chart: Used to assess distant visual acuity. Letters are presented at eye level, 20 ft away, with one eye covered. A score of 20/20 is standard. If the patient misses two letters, document it as 20/20 -2. If the patient misses more than two letters, move up a line on the chart.
- Jaeger Test: Assesses near visual acuity, used for patients over 40 years old. Test is performed at 14 inches.
- Cardinal Positions: Assess eye strength and cranial nerve function. Ask the patient to focus on an object 12 inches away and move the object through six positions in a clockwise direction. If the eye shakes, this is called nystagmus.
Eye Assessment - Additional Information
- Red Reflex: Assessing the red reflex using an ophthalmoscope is an important part of eye examination.
- Risk Factors for Eye Illness/Injuries: Increasing age, exposure to UV-B light, diabetes mellitus, cigarette smoking, alcohol use, diet low in antioxidant vitamins, high blood pressure, past eye injuries/surgery, steroid use, female gender, persistent diarrhea, gout, obesity, and beta-blocker use.
Ear Assessment - Additional Information
- Otoscopic Examination: Inspect the external auditory canal for discharge, color, consistency of cerumen, canal walls, and nodules. Inspect the tympanic membrane for shape, consistency, and landmarks.
- Whisper Test: This test evaluates the loss of high-frequency sounds. The examiner whispers a sentence, and the patient is asked to repeat it.
- External Ear Structure Assessment: Inspect and palpate the auricle, tragus, and lobule for size, shape, position, lesions/discoloration, and discharge. Palpate the auricle and mastoid process for tenderness.
- Important Note: The text above provides a comprehensive summary of key elements related to assessing abuse, various skin lesions, eye structures, ear structures, and general clinical assessment methods, but it is important to consult reliable medical sources for detailed information and professional guidance.
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Description
This quiz covers the essential aspects of assessing abuse, particularly focusing on physical examinations for victims of violence. Key considerations include equipment needed, privacy protocols, and the use of assessment tools like HITS. The material also touches on the importance of consulting a Sexual Assault Nurse Examiner for proper procedures.
