Health Assessment: Exam 2 Review

<p>Measuring blood pressure with a stethoscope. (A)</p> Signup and view all the answers

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

<p>To observe the patient's appearance and movements. (C)</p> Signup and view all the answers

<p>Immediately upon entering the room and greeting the patient. (B)</p> Signup and view all the answers

<p>Good lighting, adequate exposure, and sometimes instruments to enhance visibility. (A)</p> Signup and view all the answers

<p>A close, thorough, and concentrated observation of the patient. (D)</p> Signup and view all the answers

<p>It is the initial impression formed about the patient's overall appearance and demeanor. (C)</p> Signup and view all the answers

<p>To illuminate the ear canal and tympanic membrane (D)</p> Signup and view all the answers

<p>To direct light into the ear canal (C)</p> Signup and view all the answers

<p>Dorsa of hands and fingers (B)</p> Signup and view all the answers

<p>Use intermittent pressure for better assessment. (C)</p> Signup and view all the answers

<p>Begin with light palpation to acclimatize the patient. (D)</p> Signup and view all the answers

<p>To make the procedure more comfortable for the patient. (D)</p> Signup and view all the answers

<p>To detect the position, shape, and consistency of an organ. (A)</p> Signup and view all the answers

<p>A soft, dull, muffled sound (A)</p> Signup and view all the answers

<p>Rumbling bowel sounds (C)</p> Signup and view all the answers

<p>To detect weak or difficult-to-palpate pulses. (C)</p> Signup and view all the answers

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

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

<p>To listen to sounds produced by the body (B)</p> Signup and view all the answers

<p>Eliminating room noise and keeping the examination area quiet (A)</p> Signup and view all the answers

<p>Wet the hair on the chest before auscultating (A)</p> Signup and view all the answers

<p>Firmly pressed against the skin (D)</p> Signup and view all the answers

<p>Held gently to form a perfect seal against the skin (D)</p> Signup and view all the answers

<p>Before and after every physical patient encounter (B)</p> Signup and view all the answers

<p>To prevent the spread of disease (D)</p> Signup and view all the answers

<p>Before taking the blood pressure readings, and after each position change (supine to sitting, sitting to standing, and after 3 minutes standing) (C)</p> Signup and view all the answers

<p>3 minutes (D)</p> Signup and view all the answers

<p>A significant decrease in blood pressure upon standing (D)</p> Signup and view all the answers

<p>Suspected volume depletion (B)</p> Signup and view all the answers

<p>A drop in systolic pressure of greater than or equal to 20 mmHg after standing (C)</p> Signup and view all the answers

<p>Take baseline blood pressure after the patient rests supine (D)</p> Signup and view all the answers

<p>If the patient has a history of dehydration (B)</p> Signup and view all the answers

<p>The radial artery is less flexible, making the pulse easier to feel (A)</p> Signup and view all the answers

<p>A decrease in lung capacity due to aging (C)</p> Signup and view all the answers

<p>Decreased systolic pressure (D)</p> Signup and view all the answers

<p>Both systolic and diastolic pressures increase with age, making normal values similar to hypertension (D)</p> Signup and view all the answers

<p>Increased height (D)</p> Signup and view all the answers

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

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

<p>Stiff and rigid walls increase blood pressure. (C)</p> Signup and view all the answers

<p>Volume of circulating blood (C)</p> Signup and view all the answers

<p>Aim for approximately the same time of day and consistent clothing. (A)</p> Signup and view all the answers

<p>Encourage the patient to eat a large meal before being weighed. (B)</p> Signup and view all the answers

<p>Improved diet and exercise (B)</p> Signup and view all the answers

<p>Leaning forward with arms braced for support (C)</p> Signup and view all the answers

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

<p>To facilitate easier breathing (D)</p> Signup and view all the answers

<p>Vitamin deficiency (C)</p> Signup and view all the answers

<p>30 seconds (C)</p> Signup and view all the answers

<p>When the heart rate is slow and irregular (A), When the heart rate is fast and irregular (D)</p> Signup and view all the answers

<p>Overestimating the heart rate by 4 beats per minute (A)</p> Signup and view all the answers

<p>Flexor aspect of the wrist laterally along the radius bone (B)</p> Signup and view all the answers

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

<p>It is caused by dysfunction in the nervous system. (C)</p> Signup and view all the answers

<p>It is often resistant to treatment. (B)</p> Signup and view all the answers

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

<p>All of the above (D)</p> Signup and view all the answers

<p>To ensure children don't associate pain with happiness or sadness. (D)</p> Signup and view all the answers

<p>To measure pain intensity in children over the age of 4. (A)</p> Signup and view all the answers

<p>It utilizes visual representations tailored for children. (B)</p> Signup and view all the answers

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

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

<p>Fear and anxiety (D)</p> Signup and view all the answers

<p>Increased social engagement (B)</p> Signup and view all the answers

<p>Self-report (A)</p> Signup and view all the answers

<p>Increased appetite (C)</p> Signup and view all the answers

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

<p>Spending time with others (C)</p> Signup and view all the answers

<p>Chronic pain behaviors are highly variable and often subtle. (D)</p> Signup and view all the answers

<p>Patients with chronic pain may downplay their pain to avoid attention. (B)</p> Signup and view all the answers

<p>Synaptic cleft within the spinal cord (A)</p> Signup and view all the answers

<p>Transduction, Transmission, Perception, Modulation (D)</p> Signup and view all the answers

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

<p>Blocking the transmission of the pain impulse (D)</p> Signup and view all the answers

<p>Conscious awareness of the pain sensation (C)</p> Signup and view all the answers

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

<p>Referred pain is felt in a different location than its origin. (B)</p> Signup and view all the answers

<p>Yellowing of the sclera extending to the iris. (D)</p> Signup and view all the answers

<p>The skin remains elevated after being pinched. (C)</p> Signup and view all the answers

<p>Heart failure. (C)</p> Signup and view all the answers

<p>Reduced melanin production in hair follicles. (D)</p> Signup and view all the answers

<p>Localized non-blanchable erythema (D)</p> Signup and view all the answers

<p>Stage 4 (B)</p> Signup and view all the answers

<p>Visible fat without exposed muscle or bone (C)</p> Signup and view all the answers

<p>Localized non-blanchable color change to dark red or purple (B)</p> Signup and view all the answers

<p>They conform to the shape of the device putting pressure on skin (D)</p> Signup and view all the answers

<p>A wheal is transient and often itchy, while a papule is a more persistent, raised lesion. (A)</p> Signup and view all the answers

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

<p>Dryness of the skin (B)</p> Signup and view all the answers

<p>A mosquito bite (D)</p> Signup and view all the answers

<p>Wear sunscreen with an SPF of at least 30 and protective clothing when outdoors. (A)</p> Signup and view all the answers

<p>160° (A)</p> Signup and view all the answers

<p>Distal phalanx appears rounder and wider (B)</p> Signup and view all the answers

<p>The angle straightens to 180° (A)</p> Signup and view all the answers

<p>Angle between nail base and nail is normal (C)</p> Signup and view all the answers

<p>Continuous, sharp pain (B)</p> Signup and view all the answers

<p>Cluster headache (D)</p> Signup and view all the answers

<p>Pain that can occur multiple times a day in clusters (A)</p> Signup and view all the answers

<p>Hard, unilateral, non-tender, matted, and fixed (C)</p> Signup and view all the answers

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

<p>Cranial Nerve XI (Accessory) (C)</p> Signup and view all the answers

<p>Color uniformity (D)</p> Signup and view all the answers

<p>Head and neck, arms, axillae, and inguinal region (B)</p> Signup and view all the answers

<p>The lower face may appear unusually small, with the mouth sunken in. (B)</p> Signup and view all the answers

<p>The submandibular glands may droop and feel firm, potentially mistaken for a tumor. (A), The temporal artery may appear twisted and prominent. (C)</p> Signup and view all the answers

<p>Possible dizziness with side movements. (A)</p> Signup and view all the answers

<p>Just below the temporal artery and anterior to the tragus. (C)</p> Signup and view all the answers

<p>They are usually soft and present bilaterally. (C)</p> Signup and view all the answers

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

<p>Tip the head towards the side being examined (B)</p> Signup and view all the answers

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

<p>Have the patient hunch their shoulders and elbows forward. (B)</p> Signup and view all the answers

<p>A systematic approach is important to avoid missing any nodes. (C)</p> Signup and view all the answers

Used for mapping organ size and location by sound.

Percussion notes indicate structural density: air, fluid, or solid.

Percussion helps identify superficial abnormal masses within 5 cm depth.

Percussion is used to elicit reflexes using a percussion hammer.

Percussion cannot detect deep masses beyond 5 cm.

The initial phase of assessment involving careful scrutiny of the individual and body systems.

A general assessment of the individual that begins the inspection phase.

Instruments used to enhance visibility during inspection, like lights or magnifying lenses.

Essential for effective inspection to ensure observations are clear and accurate.

The act of concentrating and paying detailed attention during inspection.

An otoscope funnels light into the ear canal and onto the tympanic membrane or inside the nares.

Thin membrane separating the ear canal from the middle ear; also known as the eardrum.

Mechanism that directs light for better visibility in the ear canal.

Process of inspecting the ear canal and tympanic membrane using an otoscope.

Using the otoscope to inspect the nasal passages.

Different hand parts used for assessing various factors during palpation.

Best for fine tactile discrimination like skin texture and lumps.

Using fingers and thumb to detect organ position, shape, and consistency.

Palpation should be slow, systematic, and begin with light touches.

Intermittent pressure is better than ongoing pressure during deep palpation.

The first technique used during a physical assessment, involving careful observation.

Sound produced when percussion is performed on dense organs like the liver or spleen.

Used for auscultating high-pitched sounds, including breath and heart sounds.

A tool utilized to locate peripheral pulse sites during a physical examination.

Percussion over dense organs results in a soft, muffled thud at a high pitch.

Listening to sounds produced by the body using a stethoscope.

Eliminating extraneous noise and interferences during auscultation.

Use diaphragm for high-pitched sounds, and bell for low-pitched sounds.

Ensure examination room is warm and free of noise before auscultation.

Auscultation requires holding the stethoscope firmly or lightly depending on the sound.

Wash hands before and after every physical patient encounter.

Critical to prevent infection during assessments.

Perform hand washing at the start and end of patient interaction.

Practices that help prevent the spread of infections in healthcare.

Hand washing is essential for safe patient assessments and care.

Serial blood pressure measurements to assess orthostatic hypotension.

A drop in systolic pressure ≥ 20 mmHg or diastolic pressure ≥ 10 mmHg when standing.

Rest supine for 3-5 mins, then take BP and pulse while sitting, then standing.

Patients suspected of having volume depletion should have this assessment.

Assess blood pressure after standing for three minutes for accurate results.

Method to assess blood pressure changes upon standing.

A decrease of ≥ 20 mmHg in systolic pressure indicates orthostatic hypotension.

A decrease of ≥ 10 mmHg in diastolic pressure also indicates orthostatic hypotension.

Rest for 3-5 mins, measure BP sitting, then standing.

Test those with volume depletion, hypertension, or syncope symptoms.

Older adults are less likely to have fevers and more at risk for hypothermia due to changes in temperature regulation.

The normal heart rate for older adults ranges from 50 to 95 beats per minute, often with a slightly irregular rhythm.

Aging decreases vital capacity and inspiratory reserve, leading to shallower breaths and increased respiratory rate.

With age, both systolic and diastolic pressures often increase, making it harder to distinguish normal from abnormal hypertension.

Aging causes arteries to harden, increasing systolic pressure and widening pulse pressure.

Excessive growth hormone secretion in adulthood causing enlarged features.

Larger head, hands, and feet without height change.

In acromegaly, internal organs can also get bigger.

May occur alongside acromegaly due to hormone excess.

Distinctive overgrowth of facial and extremity bones.

Balances heat production and heat loss in the body.

Includes metabolism, exercise, food digestion, and external factors.

Involves radiation, sweat evaporation, convection, and conduction.

Loss of body heat through the evaporation of sweat.

Heat loss through air or water movement around the body.

The amount of blood the heart pumps per minute; increases pressure in blood vessels.

Opposition to blood flow in arteries; smaller vessels increase pressure needed.

The amount of blood in the arteries; more volume increases pressure.

The thickness of blood; thicker blood increases pressure in the vessels.

The ability of blood vessel walls to stretch; stiff walls increase pressure required to move blood.

Use a standardized scale, remove shoes and heavy clothing before weighing.

Weigh patients at the same time of day with similar clothing for accuracy.

Record weight in both kilograms and pounds for standardization and clarity.

Use either a balance scale or electronic standing scale for weighing patients.

Instruct patients to stand straight and avoid holding onto anything while weighing.

Causes may include short-term or chronic illnesses like infections or endocrine diseases.

A position where a patient leans forward to aid breathing during respiratory distress.

The tripod position is commonly used by patients with COPD for effective breathing.

Chronic illnesses like cancer or depression can lead to unexplained weight loss.

Disorders such as anorexia and bulimia can cause significant weight loss.

Use finger pads to palpate the radial pulse and count beats.

Count for a full minute if the rhythm is irregular.

Begin counting with 'zero' for the first pulse felt.

30 seconds is most accurate for normal heart rates.

Mistakes in a 15-second count lead to larger recorded errors.

Pain due to a lesion or disease in the nervous system, not following typical phases of nociceptive pain.

Pain originating from larger internal organs, often dull and deep, related to conditions like tumors or distension.

An ongoing health issue, often related to neuropathic pain, persisting long after an injury heals.

Conditions like ureteral colic, acute appendicitis, ulcer pain, and cholecystitis represent visceral pain.

Includes abnormal processing of pain messages, often leading to chronic pain conditions.

A pain scale for children showing pain intensity through faces.

Children around 4 years old can use the faces pain scale.

The scale features faces with realistic expressions, no smiles or tears.

Helps children communicate their pain level easily.

The scale ranges from 'no pain' to 'very much pain' with 6 faces.

Physiological effects of uncontrolled pain on the body systems.

Increased heart rate, blood pressure, and oxygen demand due to pain.

Pain can lead to hypoventilation and reduced cough effectiveness.

Include depression, isolation, limited mobility, and confusion.

The self-report is the most reliable indicator of a patient's pain level.

Nonverbal actions that indicate a person is experiencing chronic pain.

Actions such as bracing, rubbing, or sighing connected to chronic pain.

Short-term pain typically resulting from surgery, trauma, or kidney stones.

The patient's self-report of their pain level is the best indicator.

The first phase of nociception where tissues release pain chemicals after injury.

The second phase where the pain signal travels from the spinal cord to the brain.

The third phase, where the brain interprets and recognizes the sensation as pain.

The fourth phase where the body dampens or alters pain signals to reduce pain experience.

The four phases of pain processing: transduction, transmission, perception, modulation.

A neurotransmitter involved in transmitting pain signals during transduction.

Natural pain-relieving substances that help inhibit pain signals in modulation phase.

Deep somatic pain comes from muscles and joints, referred pain is felt elsewhere, visceral pain originates from organs.

Jaundice causes yellowing of the skin and eyes, often visible in the sclera and mouth.

Skin turgor tests elasticity by pinching skin; poor return indicates dehydration.

Generalized edema (anasarca) is often due to heart or kidney failure.

Graying hair occurs due to reduced melanin production, starting as early as the 30s.

Non-blanchable erythema on intact skin indicating early pressure injury.

Partial-thickness skin loss with exposed dermis; looks like a shallow abrasion or blister.

Full-thickness skin loss extending to subcutaneous tissue; resembles a crater.

Full-thickness skin and tissue loss exposing bone, muscle, or tendon.

Localized, non-blanchable discoloration in intact or non-intact skin; may indicate muscle damage.

A wheal is raised and transient; a papule is a solid elevation in the skin.

Xerosis refers to abnormally dry skin.

Drugs that cause sensitivity include sulfonamides and tetracyclines, requiring sun protection.

Educate patients to use sunscreen and protective clothing outdoors.

A condition characterized by the thickening and rounding of the nails, often indicating underlying health issues.

An assessment technique for clubbing by viewing the nail's profile and measuring the angle of the nail base.

A healthy nail base angle is around 160°; more than 180° indicates clubbing.

Early clubbing shows an angle straightening to 180°; late clubbing elevates the nail's edge and increases the angle beyond 180°.

Features include spongy nail base and rounded, shiny distal phalanx.

Occurs on both sides of the head, with dull, aching pain.

Always unilateral pain, sharp and excruciating, often behind the eye.

Typically lasts from 30 minutes to 7 days with gradual onset.

Very severe, can occur multiple times a day in clusters.

Can occur 1-8 times a day, often at night or upon waking.

Increased production of thyroid hormones leading to hyperthyroidism symptoms like goiter and exophthalmos.

The sternomastoid and trapezius muscles are major neck muscles innervated by cranial nerve XI.

Cancerous nodes are hard, unilateral, and non-tender; non-cancerous are soft and tender.

A mnemonic to assess pigmented lesions: Asymmetry, Border irregularity, Color variation, Diameter, Elevation, Funny looking.

Lymph nodes are accessible for examination in the head/neck, arms, axillae, and inguinal region.

Older adults may have twisted temporal arteries, sunken mouths, and drooping glands.

Located below the temporal artery and in front of the tragus of the ear.

Mild rhythmic head tremors, like nodding, can be normal in older adults.

Drooping glands may be mistaken for tumors but feel soft and are bilateral.

In older adults, the neck may compensate for spine kyphosis by showing increased anterior cervical curvature.

Method to examine lymph nodes using finger pads in a circular motion.

Ten groups of lymph nodes to palpate in routine order: preauricular, posterior auricular, occipital, submental, submandibular, jugulodigastric, superficial cervical, deep cervical chain, posterior cervical, supraclavicular.

To examine the deep cervical chain, tilt the patient's head toward the side being examined.

Locate the supraclavicular node by having the patient hunch shoulders and elbows forward for relaxation.

For the submental gland, use one hand while using the other to position the head for better access.