Exam 1 practice questions: HEALTH ASSESSMENT
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Questions and Answers

Why is it important to advocate for social justice and health equity?

  • To limit access to healthcare resources for specific populations
  • To acknowledge and address unequal health outcomes based on socioeconomic status (correct)
  • To prioritize economic gain in healthcare delivery
  • To ensure that everyone receives identical healthcare treatments

    • Which statement best describes the holistic perspective when assessing health needs?

  • Focus on medical history while ignoring family dynamics
  • Evaluate health needs in isolation from social influences
  • Acknowledge the interconnectedness of person, family, and community (correct)
  • Consider only individual health without community context

    • What is the first step a nurse should take before performing a physical exam?

  • Establish a nurse-client relationship (correct)
  • Explain the process to the client
  • Prepare the examination gown
  • Begin with the most intrusive procedures

    • What vital sign indicates potential hypoxemia in a client?

    <p>Oxygen saturation of 88%</p> Signup and view all the answers

    Which type of pain is defined as persisting for more than 3-6 months?

    <p>Chronic pain</p> Signup and view all the answers

    In a focused assessment, which aspect differentiates it from a comprehensive assessment?

    <p>It is more in-depth on specific issues</p> Signup and view all the answers

    What does a pain scale of 6/10 indicate?

    <p>Moderate pain</p> Signup and view all the answers

    Which type of pain results from damage to nervous tissues?

    <p>Neuropathic pain</p> Signup and view all the answers

    When assessing a client's complaint of lower abdominal pain, what does the nurse assess when asking the client to rate the pain on a scale of 0 to 10?

    <p>Severity of pain</p> Signup and view all the answers

    What type of pain results from nerve receptors reacting to noxious stimuli?

    <p>Nociceptive pain</p> Signup and view all the answers

    What is the next appropriate assessment to conduct for the child based on the given scenario?

    <p>Screen for Covid-19</p> Signup and view all the answers

    What is a key principle of trauma-informed care mentioned in the content?

    <p>Modeling consent and comfort in care</p> Signup and view all the answers

    What should students do if they are uncomfortable with the lab activities?

    <p>Notify their lab instructor or lab coordinator</p> Signup and view all the answers

    What is the goal of the Module One quiz mentioned in the content?

    <p>To prepare students for future exams</p> Signup and view all the answers

    What assumption will be made if students do not communicate their preferences regarding lab participation?

    <p>They are comfortable participating as described</p> Signup and view all the answers

    What is an important question to ask regarding the patient's pain?

    <p>What makes your pain better or worse?</p> Signup and view all the answers

    Which action should a nurse prioritize after reviewing the vital signs of the elderly client?

    <p>Notify the health care provider regarding tachypnea</p> Signup and view all the answers

    What is the primary purpose of the nursing assessment phase in the nursing process?

    <p>Collecting subjective and objective data</p> Signup and view all the answers

    In adhering to standard precautions, which of the following actions should a nurse perform?

    <p>Wear gloves for each client contact.</p> Signup and view all the answers

    Given the initial assessment notes, what is the most likely concern for Mrs. D?

    <p>Mrs. D is depressed</p> Signup and view all the answers

    Which of the following types of assessments is performed in life-threatening situations?

    <p>Emergency Assessment</p> Signup and view all the answers

    How might your assessment change upon entering the patient's room?

    <p>Mrs. D is taking drugs</p> Signup and view all the answers

    During which phase of the nursing interview does the nurse primarily gather detailed patient information?

    <p>Working</p> Signup and view all the answers

    What additional factor might indicate stress in Mrs. D's current circumstances?

    <p>She has 3 young children at home</p> Signup and view all the answers

    What does the acronym 'WIPE' relate to in the nursing assessment process?

    <p>Washing, Interviewing, Preparing, Educating</p> Signup and view all the answers

    Which method of communication should a nurse avoid during a patient interview?

    <p>Using biased or leading questions</p> Signup and view all the answers

    Which of the following indicates that the nurse should take immediate action?

    <p>The patient's vital signs indicate tachypnea.</p> Signup and view all the answers

    When reviewing Mrs. D's vital signs, which reading would suggest that she may need further assessment?

    <p>Heart rate of 106 beats/min</p> Signup and view all the answers

    In the context of subjective data collection, what does 'COLDSP' stand for?

    <p>Character, Onset, Location, Duration, Severity, Pattern</p> Signup and view all the answers

    What type of assessment involves gathering detailed information across all body systems?

    <p>Initial Comprehensive Assessment</p> Signup and view all the answers

    Which of the following best describes the purpose of data validation in health assessment?

    <p>Confirming the accuracy and reliability of collected data</p> Signup and view all the answers

    What is the focus of a focused/problem-oriented assessment?

    <p>Thorough assessment of a specific health concern</p> Signup and view all the answers

    Which factor is NOT recommended during effective communication in a nursing assessment?

    <p>Rushing through the interview</p> Signup and view all the answers

    Which characteristic is NOT part of the ABCDE criteria for assessing malignant melanoma?

    <p>Elevation</p> Signup and view all the answers

    What is the first clinical manifestation of MRSA typically observed?

    <p>Erythema</p> Signup and view all the answers

    Which of the following is NOT considered a risk factor for skin cancer?

    <p>Regular sunscreen use</p> Signup and view all the answers

    Which nail condition is characterized by spoon-shaped depressions?

    <p>Koilonychia</p> Signup and view all the answers

    Which symptom indicates a more serious underlying condition when assessing headaches?

    <p>Loss of consciousness</p> Signup and view all the answers

    Which of the following statements about folliculitis is true?

    <p>It can lead to pus-filled blisters.</p> Signup and view all the answers

    Which of the following would NOT typically be assessed during a head and neck examination?

    <p>Temperature of the extremities</p> Signup and view all the answers

    What key factor is associated with the development of squamous cell carcinoma?

    <p>Actinic keratosis</p> Signup and view all the answers

    What does the bottom number on a Snellen chart indicate?

    <p>The smallest line the client could read</p> Signup and view all the answers

    Which of the following symptoms indicates a potential issue with the throat or tonsils?

    <p>Painful swallowing</p> Signup and view all the answers

    Which method is NOT recommended for collecting objective data of the mouth?

    <p>Using a nasal speculum</p> Signup and view all the answers

    In the Jaeger test, what are we primarily testing for?

    <p>Near visual acuity</p> Signup and view all the answers

    What does anisocoria refer to?

    <p>Unequal pupil sizes</p> Signup and view all the answers

    Which condition is associated with a white coating on the tongue?

    <p>Candida Albicans</p> Signup and view all the answers

    What is mydriasis?

    <p>Dilation of the pupil</p> Signup and view all the answers

    What is anosmia commonly defined as?

    <p>Loss of smell</p> Signup and view all the answers

    Which test assesses the accommodation and convergence of pupils?

    <p>Convergence test</p> Signup and view all the answers

    Which symptom would likely not be associated with otitis media?

    <p>Difficulty swallowing</p> Signup and view all the answers

    What are you looking for when performing the cardinal fields of gaze test?

    <p>Smooth and symmetrical eye movements</p> Signup and view all the answers

    When assessing someone with potential mouth abnormalities, which condition would NOT be considered under abnormal findings?

    <p>Normal dental hygiene</p> Signup and view all the answers

    During the confrontation test, what is the client asked to do?

    <p>Cover one eye and count fingers</p> Signup and view all the answers

    Which of the following conditions does NOT typically involve a sore throat?

    <p>Gingivitis</p> Signup and view all the answers

    What is the main purpose of the Rinne test?

    <p>To assess the acuity of hearing through air and bone conduction</p> Signup and view all the answers

    What might cause the eye movements to be not smooth and symmetrical during an assessment?

    <p>Weak extraocular muscles</p> Signup and view all the answers

    What equipment would be least likely used for assessing the throat and tonsils?

    <p>Nasal speculum</p> Signup and view all the answers

    During the Weber test, which outcome is expected if the patient has conductive hearing loss?

    <p>Sound is heard better in the affected ear</p> Signup and view all the answers

    What does a positive Romberg test indicate?

    <p>There may be an inner ear problem</p> Signup and view all the answers

    What is presbycusis?

    <p>Gradual hearing loss related to aging</p> Signup and view all the answers

    What physical position is the patient in during the whisper test?

    <p>Seated with feet together</p> Signup and view all the answers

    Which of the following describes tinnitus?

    <p>A sensation of ringing or noise in the ears</p> Signup and view all the answers

    How is the Weber test performed?

    <p>Using a tuning fork struck and placed at the center of the head</p> Signup and view all the answers

    What does the term otalgia refer to?

    <p>Pain or discomfort in the ear</p> Signup and view all the answers

    What does a grade of 2+ indicate for tonsils on the grading scale?

    <p>Tonsils are midway between tonsillar pillars and uvula</p> Signup and view all the answers

    Which aspect of the nose should NOT be assessed during an examination?

    <p>Odor</p> Signup and view all the answers

    What observation might indicate poor nutritional status in a client?

    <p>Dry, brittle hair and skin</p> Signup and view all the answers

    In the ABCDE mnemonic for skin assessment, what does the 'E' stand for?

    <p>Evolving</p> Signup and view all the answers

    Which examination technique is primarily used to assess the sinuses?

    <p>Inspect and palpate</p> Signup and view all the answers

    What assessment finding should lead the nurse to further investigate a potential underlying illness in a 66-year-old patient?

    <p>Increasing fatigue and lethargy</p> Signup and view all the answers

    Which sign is typically assessed when checking for patency of airflow in the nose?

    <p>Nasal congestion</p> Signup and view all the answers

    What does a finding of 'kissing tonsils' correlate with on the grading scale?

    <p>Grade 4+</p> Signup and view all the answers

    What common change occurs in the breasts of older adults due to decreased estrogen levels?

    <p>Decreased size and firmness</p> Signup and view all the answers

    Which method is recommended for breast palpation?

    <p>Using the pads of three fingers</p> Signup and view all the answers

    What is the term used to describe difficulty in breathing?

    <p>Dyspnea</p> Signup and view all the answers

    What should be assessed first when a young female reports one breast is larger than the other?

    <p>Investigate if it has been a long-standing issue</p> Signup and view all the answers

    What is the indicative sound noted when a patient is dehydrated during lung auscultation?

    <p>Pleural rub</p> Signup and view all the answers

    Glandular breast tissue primarily functions in which role?

    <p>Producing and secreting milk</p> Signup and view all the answers

    Vertical, Circular, and Radial motions refer to what process?

    <p>Techniques of breast palpation</p> Signup and view all the answers

    Which lung has three lobes?

    <p>Right lung</p> Signup and view all the answers

    Which symptom describes waking at night with difficulty breathing?

    <p>Paroxysmal nocturnal dyspnea</p> Signup and view all the answers

    Which of the following is NOT considered a risk factor for breast cancer?

    <p>Regular physical exercise</p> Signup and view all the answers

    In older adults, what change is typical in breast tissue?

    <p>Decrease in glandular breast tissue</p> Signup and view all the answers

    What physical assessment technique should be used for lung inspection?

    <p>Observation</p> Signup and view all the answers

    Which statement is true regarding breast palpation technique?

    <p>Various pressures can be applied depending on the area</p> Signup and view all the answers

    Which medication could lead to adverse effects that influence lung function?

    <p>Beta-blockers</p> Signup and view all the answers

    Which structure is responsible for the pleural space around the lungs?

    <p>Parietal pleura</p> Signup and view all the answers

    What might a nurse ask a patient exhibiting adventitious breath sounds to do for further assessment?

    <p>Cough deeply</p> Signup and view all the answers

    What does a clearly heard '99' sound during auscultation possibly indicate?

    <p>Pneumonia</p> Signup and view all the answers

    What term describes a change in the sound of 'E' to sound like 'A' during auscultation?

    <p>Egophony</p> Signup and view all the answers

    What is the most likely prominent adventitious breath sound heard during inspiration?

    <p>Stridor</p> Signup and view all the answers

    What causes wheezing during respiratory assessment?

    <p>Inflammation and bronchospasms</p> Signup and view all the answers

    How should you document a patient's respiratory pattern characterized by deep and shallow breaths followed by occasional apnea?

    <p>Biot's respiration</p> Signup and view all the answers

    Which breathing pattern involves rapid and labored breaths often seen in diabetic ketoacidosis?

    <p>Kussmaul respiration</p> Signup and view all the answers

    What factors may contribute to exacerbations of a patient's asthma symptoms?

    <p>Environmental conditions</p> Signup and view all the answers

    Which of the following would NOT be classified as an adventitious breath sound?

    <p>Normal breath sounds</p> Signup and view all the answers

    What does tactile fremitus assess during a lung examination?

    <p>Vocal vibrations</p> Signup and view all the answers

    What sound would you expect to hear during auscultation in a patient with emphysema?

    <p>Wheezing</p> Signup and view all the answers

    Which of the following best describes the percussion sound known as hyperresonance?

    <p>A loud sound from overinflated lung areas</p> Signup and view all the answers

    What assessment technique is used to check for crepitus during lung examination?

    <p>Palpation</p> Signup and view all the answers

    During which part of the thoracic assessment should a nurse compare both sides of the thorax?

    <p>Inspection</p> Signup and view all the answers

    What is the purpose of whispering 'one-two-three' during auscultation?

    <p>To evaluate bronchophony</p> Signup and view all the answers

    What causes pectus excavatum during physical examination?

    <p>Skeletal deformity</p> Signup and view all the answers

    What should you expect if tactile fremitus is unequal during assessment?

    <p>Fluid in the pleural space</p> Signup and view all the answers

    What is Cheyne Stokes breathing characterized by?

    <p>Periods of deep breathing followed by apnea</p> Signup and view all the answers

    What is a common thoracic variation in older adults?

    <p>Increased dorsal spinal curve (kyphosis)</p> Signup and view all the answers

    Which of the following correctly describes the factor distinguishing kyphosis from scoliosis?

    <p>Scoliosis involves multiple regions of the spine.</p> Signup and view all the answers

    Which statement about percussion during a physical examination is true?

    <p>Percussion should be done side to side for comparison.</p> Signup and view all the answers

    Which of the following is a true statement regarding chest pain?

    <p>Chest pain can arise from multiple physiological systems.</p> Signup and view all the answers

    What respiratory change is commonly seen in older adults?

    <p>Decreased lung elasticity</p> Signup and view all the answers

    Which factor contributes to dyspnea in aging lungs?

    <p>Loss of elasticity and resiliency</p> Signup and view all the answers

    What is the expected percussion note over the heart area?

    <p>Dullness</p> Signup and view all the answers

    What potential diagnosis may be related to abnormal vital signs and chest pain or discomfort?

    <p>Coronary Artery Disease</p> Signup and view all the answers

    Which of the following factors is NOT typically considered a risk factor for coronary artery disease?

    <p>High Vitamin C Intake</p> Signup and view all the answers

    Which physical assessment technique involves listening for extra heart sounds?

    <p>Auscultation</p> Signup and view all the answers

    What condition is characterized by myocardial ischemia or infarct due to coronary artery blockage?

    <p>STEMI</p> Signup and view all the answers

    Which symptom indicates a potential issue with the heart related to cardiac rate or rhythm?

    <p>Palpitations</p> Signup and view all the answers

    Which of the following is a crucial lifestyle change for a patient diagnosed with Peripheral Artery Disease?

    <p>Quit smoking and seek a cessation program.</p> Signup and view all the answers

    What symptom would indicate potential complications for a patient with lower extremity issues?

    <p>Absence of lower extremity pulses.</p> Signup and view all the answers

    Which dietary recommendation is essential for maintaining cardiovascular health?

    <p>Foods low in saturated fat.</p> Signup and view all the answers

    What should be avoided when managing Erectile Dysfunction in patients also using fast-acting vasodilators?

    <p>Take medications prescribed for ED.</p> Signup and view all the answers

    Which follow-up action is important after a diagnosis of Peripheral Artery Disease?

    <p>Schedule screening with an ABI measurement.</p> Signup and view all the answers

    What symptom experienced by Mrs. Lim may indicate a cardiac issue?

    <p>Swollen feet</p> Signup and view all the answers

    Which objective data should be prioritized during a focused cardiac exam?

    <p>Jugular Venous Pressure</p> Signup and view all the answers

    What characteristic sound may indicate heart failure during auscultation?

    <p>Gallops (S3, S4)</p> Signup and view all the answers

    What might the presence of crackles indicate when assessing lung sounds in Mrs. Lim?

    <p>Fluid accumulation in the lungs</p> Signup and view all the answers

    What lifestyle factor is most closely linked to Mrs. Lim’s current symptoms?

    <p>High sodium intake</p> Signup and view all the answers

    Which factor should be considered when evaluating a patient’s risk for cardiac disease?

    <p>Family history of diabetes</p> Signup and view all the answers

    What assessment finding might suggest an issue with Mrs. Lim’s fluid status?

    <p>Sudden weight gain</p> Signup and view all the answers

    Which symptom is least likely to be associated with cardiovascular problems?

    <p>Sharp chest pain</p> Signup and view all the answers

    What symptom is most commonly associated with peripheral vascular issues?

    <p>Skin discoloration</p> Signup and view all the answers

    Which of the following questions would be important to ask regarding Mr. Pars' leg pain?

    <p>Is the pain consistent or does it worsen with activity?</p> Signup and view all the answers

    Which of the following conditions is least likely to be a contributor to Mr. Pars' sexual dysfunction?

    <p>Low cholesterol</p> Signup and view all the answers

    What lifestyle factor should be discussed given Mr. Pars' health history?

    <p>Alcohol consumption and smoking</p> Signup and view all the answers

    What significance does a dark wound that is not healing hold in Mr. Pars' case?

    <p>It may suggest issues with blood circulation.</p> Signup and view all the answers

    Which of the following would NOT be a relevant aspect to assess for peripheral vascular health?

    <p>Ocular health screenings</p> Signup and view all the answers

    What additional information would be most relevant to Mr. Pars' condition?

    <p>Family history of hypertension and diabetes</p> Signup and view all the answers

    What objective data would most likely be gathered during a focused peripheral vascular exam?

    <p>Peripheral pulses and capillary refill time</p> Signup and view all the answers

    What abnormal finding is suggested by the presence of a dry, black wound on the left big toe?

    <p>Infection or tissue necrosis</p> Signup and view all the answers

    Which physical exam finding indicates a lack of blood flow in the left lower extremity?

    <p>Nonpalpable left pedal pulse</p> Signup and view all the answers

    What does a positive Allen's test indicate in relation to upper extremity blood flow?

    <p>Impaired blood flow to the hand</p> Signup and view all the answers

    Which symptom is commonly associated with peripheral artery disease (PAD) that can be assessed during a physical exam?

    <p>Cool skin temperature on lower extremities</p> Signup and view all the answers

    What could be a potential cause of erectile dysfunction unrelated to peripheral artery disease?

    <p>Sleep Apnea</p> Signup and view all the answers

    Which finding would not be expected in a healthy lower extremity evaluation?

    <p>Pulses less than 2+</p> Signup and view all the answers

    How does uncontrolled diabetes potentially increase the risk of peripheral artery disease?

    <p>By worsening neuropathy and blood flow</p> Signup and view all the answers

    What abnormal observation related to skin condition suggests poor perfusion?

    <p>Mottling or discoloration of skin</p> Signup and view all the answers

    Study Notes

    Nurse’s Role in Health Assessment

    • Health assessment aims to understand a patient's physical, mental, and emotional health, guided by the American Nurses Association.
    • Utilizes the Nursing Process (ADPIE): Assessment, Diagnosis/Analysis, Planning, Implementation, and Evaluation.

    Nursing Process (ADPIE)

    • Assessment: Gather subjective (patient's feelings) and objective (measurable signs) data.
    • Diagnosis/Analysis: Analyze collected data to prioritize clinical judgments.
    • Planning: Develop solutions and determine outcome criteria.
    • Implementation: Execute the personalized care plan.
    • Evaluation: Assess if outcomes are met and revise if necessary.

    Phases of the Nursing Interview

    • Pre-introductory: Preparing for the interview.
    • Introductory: Building rapport and establishing trust.
    • Working: Engaging in detailed questioning and data collection.
    • Closing: Summarizing findings and next steps.

    Communication Techniques

    • Employ open-ended questions to gather detailed responses.
    • Avoid excessive or insufficient eye contact, distractions, and biased questions.
    • Use verbal cues like rephrasing and well-placed phrases.
    • Use nonverbal cues: facial expressions, listening, and appropriate demeanor.

    Subjective Data Collection

    • Chief Complaint (CC) and History of Present Illness (HPI) are crucial in assessing patient concerns.
    • Utilize the COLDSPA acronym for pain assessment:
      • Character
      • Onset
      • Location
      • Duration
      • Severity
      • Pattern
      • Associated factors.

    Major Steps in Health Assessment

    • Collect subjective and objective data.
    • Validate and document all findings.

    Types of Assessments

    • Initial Comprehensive Assessment: Thorough overview of all body systems, personal, family, and health history.
    • Ongoing/Partial Assessment: Follow-up on body systems and health patterns.
    • Focused/Problem-Oriented Assessment: In-depth examination of specific issues.
    • Emergency Assessment: Immediate evaluation in life-threatening situations.

    Framework for Assessments

    • Focused: Collects subjective data relating to the chief complaint and personal health history.
    • Comprehensive: Encompasses biographic data, past medical history, psychosocial factors, and a review of systems.

    Social Determinants of Health

    • Emphasizes the importance of understanding health disparities and advocating for health equity.
    • Encourages nurses to recognize that individual needs vary and require tailored approaches.

    Screening Tools

    • SBIRT: Screening, Brief Intervention, and Referral to Treatment for substance use, incorporating tools like CAGE and AUDIT for alcohol use disorder.

    Physical Exam Approach

    • Establish a nurse-client relationship before starting the exam.
    • Explain processes to ensure comfort and understanding.
    • Start with non-invasive procedures.

    Vital Signs Norms

    • Temperature: 98.6°F (37°C)
    • Pulse: 110 bpm
    • Respiratory Rate: 16 breaths/min
    • Oxygen Saturation: 88%
    • Blood Pressure: 120/76 mmHg
    • Pain Score: 6/10

    Types of Pain

    • Acute: Sudden onset, resolves with healing.
    • Chronic: Lasts longer than 3-6 months, can be debilitating.
    • Nociceptive: Arises from tissue damage.
    • Neuropathic: Results from nerve damage.

    Clinical Scenarios

    • Focused assessments target specific clinical issues instead of comprehensive evaluations that consider all body systems.
    • Pain severity is assessed by asking patients to rate their discomfort on a scale of 0 to 10.

    Quiz Information

    • A module quiz will be available, covering both module content and syllabus administration, allowing multiple attempts to achieve a passing grade.

    Laboratory Participation

    • Emphasizes consent and trauma-informed care in lab settings, ensuring student comfort and safety during peer assessments.

    Skin Cancer Risk Factors

    • Malignant melanoma is characterized by the ABCDE method for assessment:
      • Asymmetry: Uneven halves of moles
      • Border: Irregular or scalloped edges
      • Color: Varied pigmentation (multiple colors in one mole)
      • Diameter: Moles larger than 6mm
      • Evolving: Changes in size, shape, or color
    • Common risk factors for skin cancer include:
      • Sun exposure: Significant risk factor
      • Moles: Presence of atypical moles increases risk
      • Fair skin and light hair: Higher susceptibility
      • Age: Increased risk with advancing age
      • Genetics: Family history of skin cancer plays a role
      • Actinic keratosis: Precursor lesions
      • Ultraviolet radiation: Key environmental contributor

    Hair and Nail Conditions

    • Common hair issues include:
      • Folliculitis: Inflammation of hair follicles
      • Alopecia: Hair loss
      • Tinea capitis: Fungal infection of the scalp
      • Lice: Infestation affecting hair
    • Nail conditions to recognize:
      • Koilonychia: Spoon-shaped nails indicating iron deficiency
      • Pitting: Small indentations in nails, often associated with psoriasis
      • Longitudinal ridging: Vertical lines on nails
      • Yellow nail syndrome: Associated with respiratory issues
      • Paronychia: Infection of nail folds

    Methicillin Resistant Staphylococcus aureus (MRSA)

    • Clinical manifestations include:
      • Infected area, erythema, edema, and pain
      • Warm to touch with possible pus drainage
      • Fever in patients can indicate systemic involvement
    • Treatment involves antibiotics like Vancomycin
    • Potential serious complications: sepsis, respiratory failure, amputation, or death

    Assessing the Head and Neck

    • Key history elements include family history of headaches, concussions, and strokes
    • Inquire about lifestyle habits: medications, smoking, alcohol, and drug use
    • Observe for new lumps, dizziness, or any swallowing difficulties
    • Physical examination requires attention to head alignment, posture, and movement.

    Eye Assessments

    • Snellen chart is used for testing distant visual acuity; top number indicates distance, bottom number indicates the last line read.
    • Jaeger test assesses near visual acuity held 14 inches away.
    • Eye movement assessment includes checking pupil reaction:
      • Mydriasis: dilation of the pupil
      • Miosis: constriction of the pupil
    • Cardinal fields of gaze: checks for smooth eye movements; nystagmus may indicate underlying issues.
    • Confrontation test evaluates peripheral vision through finger counting.

    Auditory Assessments

    • The Weber test uses a tuning fork placed at the center of the head; sound lateralizes to the affected ear in conductive loss.
    • The Rinne test compares air and bone conduction, with normal hearing showing air conduction greater than bone conduction.
    • The Romberg test evaluates balance; a positive sign indicates potential vestibular disorders.
    • Common auditory abnormalities:
      • Otalgia: Earache
      • Tinnitus: Ringing in ears
      • Presbycusis: Age-related hearing loss

    Mouth, Throat, Nose, and Sinuses Assessment

    • Subjective questions should cover pain, taste/smell changes, drainage, and any lesions.
    • Key vocabulary includes:
      • Epistaxis: Nosebleed
      • Anosmia: Loss of smell
      • Dysphagia: Difficulty swallowing
    • Objective data collection involves inspection of lips, teeth, and buccal mucosa; palpation of sinuses is also performed.

    Throat and Nasal Assessments

    • Inspect tonsils using a grading scale:
      • 0: removed
      • 1+: visible
      • 2+: midway between pillars and uvula
      • 3+: touching uvula
      • 4+: kissing tonsils
    • Assessment of nasal condition includes symmetry, mucosa, tender areas, and any masses/polyps.

    Assessment Questions

    • Symptoms of dry, brittle hair and flaky skin may indicate poor nutritional status.
    • In assessing moles, 'C' in ABCDE stands for Color.
    • For a 66-year-old with fatigue and cold intolerance, further assessment should be prioritized, potentially looking into thyroid function or iron deficiency.

    Common Breast Variations in Older Adults

    • Decreased size and firmness of breasts due to reduced estrogen levels.
    • Shift from glandular tissue to increased fatty tissue, leading to pendulousness and sagging.
    • Nipples may appear smaller and flatter with reduced erectile ability; breasts feel more granular.

    Breast Palpation Techniques

    • Importance of knowing Last Menstrual Period (LMP) for identifying cyclical breast tenderness.
    • Pads of three fingers recommended for effective palpation; techniques include circular, wedge, or vertical strip motions.
    • Light, medium, or firm palpation, adjusting according to breast tissue characteristics.

    Management of Breast Size Differences

    • Inquiry about new breast size variations should be prioritized in patient assessments to rule out pathology.

    Glandular Breast Tissue Functions

    • Provides structural support and is crucial for milk production; also influences breast size and shape.

    Breast Palpation Descriptions

    • Vertical, circular, and radial refer to techniques used in breast palpation assessments.

    Risk Factors for Breast Cancer

    • Key risk factors include genetics, obesity, and the number of pregnancies; caffeine not considered a significant risk.

    Variations in Older Adults' Breasts

    • Older adults typically exhibit decreased glandular tissue and increased fatty tissue, alongside a decline in firmness.

    Lung Assessment Subjective Data

    • History of present illness should include symptom onset, type of symptoms, changes over time, triggers, and recent infections.
    • Medical history includes chronic respiratory illnesses, smoking status, and family history of respiratory diseases.

    Lung Anatomy

    • Right lung features three lobes; pleural layers include parietal and visceral pleura, surrounding pleural space.
    • In dehydrated patients, pleural rub may be detected during auscultation.

    Common Respiratory Terms

    • Familiarize with terms such as dyspnea, cough, orthopnea, and sleep apnea for comprehensive lung assessment.

    Lung Assessment Techniques

    • Objective assessment follows a stepwise order: inspection, palpation, percussion, and auscultation.
    • Chest observations include color, shape, respiratory effort, and use of accessory muscles.

    Thoracic Abnormalities

    • Conditions such as pectus excavatum and barrel chest affect thoracic shape and indicate underlying respiratory issues.

    Palpation and Percussion in Lung Assessment

    • Assess tactile fremitus with "99" for fluid presence; unequal fremitus may indicate underlying conditions.
    • Percussion tones vary: hyperresonance indicates air trapping (e.g., emphysema), dullness could suggest fluid or mass.

    Auscultation Techniques

    • Adventitious sounds include wheezing (indicating bronchospasm) and crackles; stridor may indicate upper airway obstruction.
    • Documenting abnormal sounds (e.g., bronchophony, egophony) helps rule out serious conditions like pneumonia.

    Patient Education on Respiratory Health

    • Educate on smoking dangers, environmental factors, vaccination importance, and managing chronic conditions through physical activity.

    Variations in Older Adults' Lung Function

    • Common changes include increased chest diameter, diminished thoracic expansion, reliance on accessory muscles, and decreased cough reflex.
    • Aging lungs experience reduced elasticity, lowered lung capacity, and increased risk for respiratory ailments.

    Differences between Kyphosis and Scoliosis

    • Kyphosis involves a rounded thoracic spine, while scoliosis presents as lateral spine curvature; both can affect respiratory function.

    Chest Pain Assessment

    • Chest pain can arise from a variety of sources: cardiac, vascular, gastrointestinal, musculoskeletal, or skin-related, emphasizing the need for thorough evaluation.

    Cardiovascular and Peripheral Vascular Systems Assessment

    • Objectives encompass identifying coronary artery disease (CAD) risk factors and effective reduction strategies.
    • Emphasis on accurate patient interviews specific to heart and neck vessels.
    • Importance of performing thorough physical assessments involving inspection, auscultation, palpation, and percussion techniques.
    • Recognition of age-related findings in heart and neck vessel assessments.

    Heart Disease Causes and Symptoms

    • Subjective symptoms: chest pain, fatigue, shortness of breath, palpitations.
    • Objective indicators: abnormal vital signs (VS), abnormal electrocardiograms (EKG), signs of edema.
    • Key pathophysiological processes: myocardial ischemia, heart failure, atrial fibrillation.
    • Potential diagnoses include coronary artery disease, myocardial infarctions (STEMI, NSTEMI), cardiomyopathy.

    Coronary Artery Disease

    • Risk factors include lifestyle choices (diet, exercise, tobacco use), family history, obesity, and diabetes.
    • Myocardial ischemia occurs due to cellular injury from obstructed blood flow.

    Case Studies Overview

    • Mrs. Lim presents with swollen feet, orthopnea, and fatigue indicating potential heart failure.
    • Focus on gathering vital signs, fluid status, and heart sounds during physical examinations.
    • Mr. Pars presents with leg discoloration, non-healing wounds, and erectile dysfunction, linking peripheral vascular disease and diabetes.

    Physical Examination Techniques

    • Inspection and palpation of carotid and jugular veins, avoiding pre-palpation auscultation for bruits.
    • Assess jugular venous pressure, heart sounds, lung sounds, and ensure careful examination of older adults to avoid complications.

    Normal vs Abnormal Findings

    • Normal findings for vascular assessments: warm skin, hair presence, appropriate skin color, and intact pulses.
    • Abnormal findings suggest vascular issues: cool skin, hair loss, discoloration, delayed capillary refill, and the presence of bruits.

    Diagnoses and Plan of Care

    • Mr. Pars diagnosed with Peripheral Artery Disease (PAD) and erectile dysfunction; recommended diagnostic procedures and lifestyle changes.
    • Patient education includes smoking cessation, diabetes management, regular exercise, healthy diet maintenance, and monitoring treatment interactions.

    Key Takeaways for Clinical Practice

    • Conduct thorough history taking to identify risk factors and symptoms.
    • Utilize objective data from physical exams to inform potential diagnoses.
    • Educate patients on the importance of lifestyle modifications to manage cardiovascular and peripheral vascular health effectively.

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    Description

    This quiz explores the essential role of nurses in health assessment, focusing on the ADPIE nursing process. It emphasizes data collection methods and the importance of both subjective and objective data in clinical judgments. Test your understanding of holistic nursing practices and the assessment process.

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