GEPN Health Assessment Final Exam Review

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Questions and Answers

What is the primary purpose of percussion during an abdominal assessment?

  • To assess the distribution of gas, viscera, and masses (correct)
  • To evaluate skin color and texture
  • To listen for bowel sounds
  • To measure abdominal circumference

Which of the following describes normal bowel sounds during auscultation?

  • 5-34 clicks/min (correct)
  • Fewer than 5 clicks/min
  • More than 34 clicks/min
  • Irregular and sporadic sounds

Which action should be performed first during the abdominal assessment?

  • Palpation
  • Auscultation
  • Percussion
  • Inspection (correct)

What is one of the purposes of light palpation during an abdominal assessment?

<p>Identifying abdominal tenderness and muscular resistance (A)</p> Signup and view all the answers

What sound is produced during percussion that indicates normal findings?

<p>Tympany (B)</p> Signup and view all the answers

Which aspect of the mental status exam assesses whether a patient is aware of their name and the names of familiar individuals?

<p>Orientation to person (D)</p> Signup and view all the answers

What does the assessment of a patient's posture and motor behavior help to determine?

<p>Emotional state (C)</p> Signup and view all the answers

Which component is NOT part of the neurological examination for determining a patient's alert and oriented status?

<p>Social interactions (B)</p> Signup and view all the answers

What does the presence of bruits indicate?

<p>An aortic aneurysm (A)</p> Signup and view all the answers

What is considered when assessing a patient's speech characteristics in the mental status exam?

<p>Patient's rate of speech (D)</p> Signup and view all the answers

Which observation would be a sign of facial immobility during a mental status examination?

<p>Flat or expressionless face (C)</p> Signup and view all the answers

Which of the following characteristics is NOT true about splenomegaly?

<p>It is always a sign of disease. (C)</p> Signup and view all the answers

How should you assess for bruits during an abdominal exam?

<p>Auscultate without palpating. (B)</p> Signup and view all the answers

During the mental status exam, if a patient knows the current location but cannot recall the time, what should that indicate?

<p>Impaired orientation to time (D)</p> Signup and view all the answers

What would indicate appropriate grooming and dress during a mental status assessment?

<p>Clothing suitable for the climate (D)</p> Signup and view all the answers

Which of the following abdominal structures is typically non-palpable?

<p>Spleen (A)</p> Signup and view all the answers

What aspect should be evaluated if a patient exhibits anxious fidgeting during the assessment?

<p>Emotional stability (C)</p> Signup and view all the answers

What type of abdominal pain tends to be difficult to localize?

<p>Visceral pain (D)</p> Signup and view all the answers

What is the hallmark finding of guarding during a physical exam?

<p>Voluntary abdominal wall contraction (C)</p> Signup and view all the answers

What should you NOT do if bruits are heard during auscultation of the abdomen?

<p>Palpate the aorta (C)</p> Signup and view all the answers

Which abdominal organ is regularly assessed for enlargement by palpation below the 12th rib?

<p>Kidneys (B)</p> Signup and view all the answers

Rebound tenderness may be suggestive of which condition?

<p>Peritonitis (B)</p> Signup and view all the answers

What is the usual size range for a normal liver?

<p>6-12 cm (B)</p> Signup and view all the answers

What is the normal range of bowel sounds heard during auscultation of the abdomen?

<p>5-34 clicks/min (A)</p> Signup and view all the answers

Which percussion sound is typically expected when assessing a healthy abdomen?

<p>Tympany (B)</p> Signup and view all the answers

During light palpation, what is NOT a sign that should be assessed?

<p>Respiratory rate (D)</p> Signup and view all the answers

What is the purpose of performing auscultation before palpation during an abdominal assessment?

<p>To avoid altering bowel sounds (D)</p> Signup and view all the answers

If dullness is heard during percussion, what might this indicate about the underlying structures?

<p>Presence of excess fluid or solid masses (C)</p> Signup and view all the answers

Which of the following components is part of the screening neurological examination for determining a patient's alertness?

<p>Motor system assessment (B)</p> Signup and view all the answers

What aspect of the mental status examination does the evaluation of a patient's grooming and hygiene primarily assess?

<p>Personal care and social interaction (C)</p> Signup and view all the answers

When assessing a patient’s alertness, which of the following correctly evaluates the time component?

<p>Determining if they know the day of the week (C)</p> Signup and view all the answers

Which characteristic of speech might indicate a patient is experiencing a significant mental health issue?

<p>Rate of speech (D)</p> Signup and view all the answers

In assessing a patient's facial expression during a mental status examination, which of the following would suggest a potential issue?

<p>Flat affect regardless of the topic (C)</p> Signup and view all the answers

Where is the location in which a patient needs to be oriented to evaluate their situational understanding?

<p>The name of the hospital or clinic (B)</p> Signup and view all the answers

If a patient's speech is described as 'fast and loud,' what might this indicate regarding their mental status?

<p>Possible anxiety or mania (C)</p> Signup and view all the answers

What does assessing a patient's tense posture and anxious fidgeting primarily help identify?

<p>Emotional distress or anxiety (D)</p> Signup and view all the answers

What is the typical reason for auscultating before palpating during an abdominal examination?

<p>To avoid compressing a vessel that may be partially occluded (B)</p> Signup and view all the answers

Which abdominal area is assessed for splenomegaly during clinical examination?

<p>At the anterior axillary line (D)</p> Signup and view all the answers

What characteristic feature differentiates parietal pain from visceral pain?

<p>Parietal pain can be easily located (C)</p> Signup and view all the answers

What does the presence of rigidity during an abdominal assessment suggest?

<p>A possible peritoneal inflammation (C)</p> Signup and view all the answers

How does rebound tenderness present in a clinical examination?

<p>Pain upon the release of pressure from the abdomen (A)</p> Signup and view all the answers

What finding may suggest aortic aneurysm when auscultating the abdomen?

<p>Detection of bruits (C)</p> Signup and view all the answers

In which scenario would you suspect splenomegaly during an abdominal assessment?

<p>Dullness is noted on percussion at the anterior axillary line (D)</p> Signup and view all the answers

What action should be avoided if bruits are heard during abdominal auscultation?

<p>Proceeding with deep palpation of the abdomen (D)</p> Signup and view all the answers

Which characteristic is true regarding the normal size of the abdominal aorta?

<p>Normal size ranges from 2.5-3 cm (A)</p> Signup and view all the answers

Which condition is most likely associated with parietal abdominal pain?

<p>Appendicitis leading to peritonitis (A)</p> Signup and view all the answers

Flashcards

Abdominal Assessment

Systematic examination of the abdomen, evaluating organs, tissues, and their functions within the abdominal cavity.

Abdominal Auscultation

Listening to the sounds produced by the organs within the abdomen, using a stethoscope.

Abdominal Percussion

Tapping on the abdomen to detect the presence of gas, fluids, or solid organs.

Abdominal Palpation

Feeling the abdomen by applying pressure to assess tenderness, organs.

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Normal Bowel Sounds

5-34 clicks per minute, indicative of normal bowel function.

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Alert and Oriented Status

Patient's awareness of their surroundings and self, assessed by asking questions about person, place, time, and situation.

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Mental Status Exam Components

Aspects of a patient's mental state evaluated during a neurological assessment.

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Appearance and Behavior

Evaluates patient posture, motor activity, clothing, grooming, and facial expressions.

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Speech and Language

Assessment of the patient's speech, including quantity, rate, loudness, and articulation.

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Patient's Posture

Assessing the patient's physical stance for abnormalities like tension or restlessness.

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Grooming

Assessment of the patient's personal appearance and hygiene.

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Appropriate Facial Expressions

Assessing the patient's facial expressions to match the current interaction and topic.

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Orientation Assessment

Assess knowing person, place, time, and situation.

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Bruits

Murmur-like sounds in a vascular structure, caused by tumultuous blood flow in an artery.

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Where to listen for bruits

Over the abdominal aorta, renal arteries, iliac arteries, and femoral arteries.

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Auscultate before palpating

Listen to the abdomen before touching or feeling it.

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Normal liver size

Typically spans 6-12 cm.

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Splenomegaly

An enlarged spleen, often 8 times more likely when palpable.

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Causes of kidney enlargement

Hydronephrosis, cysts, and tumors can cause kidney enlargement.

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Parietal pain

Steady, aching pain aggravated by coughing or movement. It is usually more severe than visceral pain.

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Visceral pain

Gnawing, burning, or cramping pain that's difficult to localize.

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Referred pain

Pain originating from a different location. For example, pain originating elsewhere that manifests in the abdomen

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Abdominal guarding

Voluntary contraction of abdominal muscles that can be involuntary during palpation, often accompanied by grimacing; usually a sign of peritoneal inflammation.

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Orientation: Time

Does the patient know the time of day, day of the week, month, season, and year?

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Orientation: Situation

Does the patient know what has happened or is happening? Do they understand why they are there?

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Appearance and Behavior: Posture

Assess the patient's physical stance for abnormalities like tension or restlessness.

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Speech and Language: Quantity

Is the patient talkative or silent? Is it usual or unusual for them?

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Speech and Language: Rate

Is the patient's speech fast or slow?

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Speech and Language: Loudness

Is the patient's speech loud or soft?

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Speech and Language: Articulation

Are the words clear and distinct?

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Facial Expression Assessment

Evaluate if the patient's facial expression matches the topics being discussed. Look for expressions of anxiety, depression, apathy, anger, elation, or facial immobility.

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Abdomen: What's inside?

The abdomen is divided into four quadrants. Each quadrant contains specific organs. Knowing their locations is essential for diagnosing medical conditions.

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Why Auscultate First?

Auscultation, or listening to bowel sounds, is performed before palpation because palpation can alter the natural sounds produced by the intestines.

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Percussion: What does it tell us?

Percussion, tapping on the abdomen, helps assess the amount and distribution of gas, fluids, and solid organs.

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Palpation: Light vs. Deep

Light palpation gently feels the abdomen for tenderness and superficial organs. Deep palpation goes deeper to assess organs and masses.

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Liver Span: What's Normal?

The normal liver span is 6-12 cm. This is measured by percussion to assess the liver's size.

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What are bruits?

Bruits are a murmur-like sound heard in a blood vessel, indicating turbulent blood flow through an artery.

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Where are bruits typically auscultated?

Bruits are usually listened for over the abdominal aorta, renal arteries, iliac arteries, and femoral arteries.

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Why auscultate before palpating?

Auscultating before palpating is important because palpation can compress already partially blocked arteries, making it difficult to hear the sounds.

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Guarding

Guarding is a voluntary contraction of abdominal muscles, often accompanied by grimacing, which can become involuntary during palpation. It's a sign of peritoneal inflammation.

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Rebound tenderness

Rebound tenderness is pain experienced when pressure on the abdomen is released. It's a sign of peritonitis, or inflammation of the peritoneum.

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Study Notes

GEPN Health Assessment Final Exam Review

  • The exam has 75 questions in total
  • Neurological questions: 30
  • Abdominal questions: 30
  • Integumentary (skin) questions: 15

Neurological Exam Components

  • Mental status
  • Cranial nerves
  • Sensory system
  • Motor system

Neurological Exam: Determining Alert and Oriented Status

  • Person: Does the patient know their name and those of relatives or familiar healthcare staff?
  • Place: Does the patient know where they are (clinic/hospital name, city, state)?
  • Time: Does the patient know the time of day, day of the week, month, season, and year?
  • Situation: Does the patient know what is happening and why they are there?

Mental Status Exam Components: Appearance and Behavior

  • Posture and motor behavior: Assessing for tense posture, restlessness, and anxious fidgeting
  • Dress, grooming, and personal hygiene: Is the clothing appropriate for the weather and is the patient's personal hygiene appropriate?
  • Facial expression: Appropriate to topics being discussed, assessing for anxiety, depression, apathy, anger, elation, or facial immobility
  • Speech and language:
    • Quantity: Assessing how talkative the patient is, compared to baseline
    • Rate: How fast or slow is the speech?
    • Loudness: Is the speech loud or soft?
    • Articulation: Assessing the clarity and distinctness of words
    • Fluency: Assessing the rate, flow, and melody of speech
    • Aphasia: Impaired comprehension with fluent speech, or preserved comprehension but slow, nonfluent speech

Mental Status Exam Components: Mood and Cognition

  • Mood: Asking about the patient's usual mood and how it has changed -Assess for sadness, contentment, joy, euphoria, elation, anger, rage, anxiety, detachment, or indifference
  • Thoughts and perceptions: Assessing the logic, relevance, organization, and coherence of thought processes, listening for speech patterns, and assessing thought content
  • Cognitive function:
    • Orientation: Alert and oriented status
    • Attention: Concentration ability
    • Remote memory: Past events, birthdays, school names
    • Recent memory: Current day, weather
    • New learning ability: four unrelated words, recall in 3-5 minutes

Glasgow Coma Scale

  • A reliable assessment tool for level of consciousness, particularly after brain injury.
  • Three sections: eye opening, verbal response, and motor response.
  • Scores range from 3 (most severe) to 15 (least severe). Decreasing scores after head injury relate to higher mortality.

Cranial Nerves

  • 12 pairs numbered based on how they arise from nuclei
  • (M) = Motor, (S) = Sensory, (B) = Both
  • mnemonic for the order and function is "On Old Olympus' Towering Top, A Finn And German Viewed A Hop"

Deep Tendon Reflexes: Grading

  • 4+ (Very brisk, hyperactive with clonus)
  • 3+ (Brisk)
  • 2+ (Normal)
  • 1+ (Diminished/hyporeflexia)
  • 0 (Absent/areflexia)

NINDS Scale for Tendon Reflex Assessment

  • Scoring for tendon reflexes, grading scale from 0 to 4 (absent to enhanced).
  • Description of different scores, including those with clonus(involuntary rhythmic oscillations) noted in the reflex

Deep Tendon Reflexes

  • Biceps (C5/C6)
  • Brachioradialis (C6)
  • Triceps (C7)
  • Patellar (L4)
  • Achilles (S1)

Hyporeflexia

  • Decreased/absent reflex response in muscles
  • Cause potentially stemming from lower motor neurons or CNS disorders (spinal cord injuries, muscular atrophy, Guillain-Barre, ALS, and hypothyroidism)
  • Symptoms include gradual onset, increasing muscle weakness, difficulty holding objects, difficulties walking or standing, muscle atrophy, and dependance on cause.

Cerebral Vascular Accidents (Strokes)

  • Use the mnemonic "BE FAST" to remember common symptoms:
    • Balance: Loss of balance, headache, or dizziness
    • Eyes: Sudden changes in vision (loss or double vision)
    • Face: Does one side of face droop?
    • Arm: Weakness in arm, especially on one side.
    • Speech: Difficulty speaking
    • Time: Time to call emergency services

Stroke Risk Factors

  • High blood pressure
  • High cholesterol
  • Diabetes
  • Smoking
  • Alcohol use
  • High stress levels
  • Heart disease
  • Obesity and lack of exercise.

Traumatic Brain Injuries:

  • Concussion
  • Contusion
  • Coup Contrecoup
  • Diffuse Axonal Injury

Pressure Injuries

  • Contributing Factors: Advanced age, moisture, friction, shear, poor skin hygiene, diabetes, medication use, and decreased sensory perception
  • common locations: Sacrum, heels, hips, coccyx, elbows.

Staging of Pressure Injuries

  • Stage 1: Skin is intact with non-blanchable redness
  • Stage 2: Partial thickness loss.
  • Stage 3: Full thickness loss, adipose tissue exposed.
  • Stage 4: Full thickness loss with exposed bone, tendon, or muscle.
  • Unstageable: Base of wound obscured by slough or eschar.
  • Deep tissue injury: May appear as skin ulcer, but involves deeper tissue and can appear as purple or maroon discoloration.

Assessment of Pressure Injuries

  • Size, drainage, presence of sutures, lines, odor, color, and location
  • Measurements: Length, width, and depth

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