HA Exam 1 Review - Fall 2024- NO ANSWERS-1.pdf

HEALTH ASSESSMENT EXAM 1 REVIEW EXAM 1 DETAILS AND TIPS  EX AM DETAILS Exam 1 takes place Week 4 (9/16-9/20). Please arrive 15 minutes early. Exam consists of 50 questions, and you will have 60 minutes to complete the exam Scrap paper will be provided Covers Module...

HEALTH ASSESSMENT EXAM 1 REVIEW EXAM 1 DETAILS AND TIPS  EX AM DETAILS Exam 1 takes place Week 4 (9/16-9/20). Please arrive 15 minutes early. Exam consists of 50 questions, and you will have 60 minutes to complete the exam Scrap paper will be provided Covers Modules 2, 3, and 4 content: Module 2: Assessing Skin, Hair, and Nails, Nutrition + Assessing HEENT Module 3: Assessing the Thorax and Lungs, Assessing Breasts and Lymphatics Week 3: Assessing the Heart and Neck Vessels; Peripheral Vascular System  STUDY STRATEGIES Review in-class case studies Review Homeworks Use the book for clarifications Work through learning objectives Review the modules Use CoursePoint resources  GENERAL EXAM TIPS Read the question and make sure you know what it is asking Eliminate answer choices Please sleep – Take care of yourself Practice the assessments (think about lab and relating topics to actions) A QUICK CONTENT OVERVIEW  WEEK 2: ASSESSING NUTRITION Components of the Assessment Medications, allergies Anthropometric measurements Altered Nutrition and Hydration Objective Data Is and Os Risk Factors Equipment Hydration Assessment Nutritional problems, food Scale, metric measuring tape, Physical Exam safety, ability to digest and store skin fold caliper Areas of focus nutrients, food sensitivities, Measurements safety issues Health Promotion BMI Food deserts, limited access, Healthy eating patterns lifestyle Underweight: skin Color turgor Review medical record Texture Edema Capillary refill PRIVACY Rashes Comfortable environment Know names of different types Braden scale for skin breakdown of lesions Position pt Assessment of scalp/hair BRADEN SCALE Measurements and screenings Hygiene ABCDE for assessing suspicious Weight, height, BMI, skin lesions Amount and distribution of hair skin lesions VS Physical exam process Assessment of nails Inspection then palpation Cleanliness  WEEK 2: ASSESSING HEENT Head and Neck Abnormals Mouth, Nose, Throat, and Distant Visual Acuity: Snellen Sinuses Head Chart Inspection and palpation Size, shape, movements Near Visual Test: Jaegar Test Odor Face Pupillary reaction to light, cardinal Color (ex: pallor,) Symmetry, features, movement, fields of gaze expression, skin Hyperplasia Ears Temporal artery and TMJ Inspect teeth Hearing Loss Neck Appearance and texture of tongue Conductive vs. Sensorimotor Range of motion Patency of airflow Whisper Test Movement Exudate from nose Weber and Rinne tests Lymph nodes Tenderness Romberg test Abnormals Abnormals Eyes  WEEK 3: ASSESSING THE THORAX AND LUNGS Subjective Assessment Positioning: tripoding Auscultation PMH and HPI Nails Types of breath sounds Family history Thorax and any Bronchial, vesicular and abnormalities bronchovesicular Lifestyle and health practices: Smoking Respirations Voice Sounds Lung cancer risk factors: Use of accessory muscles, Bronchophony, egophony, smoking, radon exposure, work of breathing, chest and whispered asbestos, toxins, diet, expansion pectoriloquy genetics Palpation Adventitious breath sounds S/s of interest: dyspnea, cough, orthopnea, paroxysmal Crepitus Crackles, wheezing, nocturnal dyspnea, sleep apnea stridor Fremitus Objective Assessment Older Adults Percussion Inspection Kyphosis, deep breathing Tone: want to hear difficulty, decrease Color of face and lips resonance expansion HELPF UL I M AG E HELPF UL I M AG E HELPF UL I M AG E  WEEK 3: ASSESSING THE BREASTS AND LYMPHATIC SYSTEM Subjective Assessment Positions: sitting, hands on hips, tenderness hands over head, leaning Menstrual history forward, supine Older Adults: less firm, flatter nipples, granular Pregnancies and breastfeeding Inspection: Abnormalities Breast surgeries Breast size, shape, color and texture Gynecomastia in males Any breast concerns Nipple appearance S/s of breast cancer Breast cancer Palpation: Instruction on how to Breast self exams and lifestyle perform a breast self exam practices Breast: consistency, masses, tenderness, texture, Examine in the shower Contraception temperature Use of positioning Mammograms Nipple: masses, tenderness, Circular motion Objective Assessment discharge Anatomical landmarks: 4 Be familiar with methods breast quadrants, Tail of Spence Lymph: rash, palpable, HELPF UL I M AG E HELPF UL I M AG E  MODULE 4: ASSESSING THE HEART AND NECK VESSELS Know s/s Lifestyle Assessment positions? Ex: MI = chest pain/discomfort Objective Data What do we expect to hear with extra heart CAD risk factors – family history, What equipment will you sounds and murmurs poor diet, smoking need? Know how to grade a Minimize modifiable risk General Assessment – murmur factors – diet, smoking Assessment order? cessation, exercise APETM o Neck: JVP/JVD, auscultate 5 As of smoking THEN palpate carotids Older Adult Considerations Subjective Data o Inspect: Anterior chest Gentle with palpation r/t atherosclerosis HPI – COLDSPA, chest pain, o Palpate: Apical pulse, pulses, SOB, palpitations, fatigue lifts vs. thrills Apical may not be as easy to palpate PMH o Auscultate: rate and rhythm, S1 and S2, extra Fam Hx heart sounds, murmurs HELPF UL I M AG E HELPF UL I M AG E  MODULE 4: ASSESSING THE PERIPHERAL VASCULAR SYSTEM Arteries vs. Veins Fam Hx o What do you do if you can't feel pulses Major arteries of arms and legs Lifestyle o Manual compression Types of veins Objective Assessment test, trendelenburg test, Homan's sign Lymphatic System What equipment will you need? Arterial Insufficiency Fluid exchange, connection b/w Upper Extremities arterioles and venules, EQUILIBRIUM o S/S o Inspection: Edema, venous Peripheral Vascular System patterning, skin color, clubbing o Testing and what to expect Know risk factors o Palpation:Temp, cap refill, pulses, Venous insufficiency lymph nodes, Allen test o Modifiable risk factors o S/S Lower Extremities PAD, DVT, venous stasis Older Adult Considerations o Inspection: Color, hair distribution, Subjective Assessment lesions/ulcers, edema Hair loss HPI – COLDSPA, skin changes, pains, o Auscultation: Femoral artery Smaller and fewer lymph nodes veins, sores, wounds, swelling, swollen/painful nodules, sexual activity o Palpation: Varicosities are common changes Temp, superficial inguinal lymph nodes, pulses PMH HELPF UL I M AG E HELPF UL I M AG E HELPF UL I M AG E PRACTICE QUESTIONS  1. A N U R S E I S I N T E RV I E W I N G A C LI E N T R E G A R D I N G H E R L I F E S T Y L E A N D H E A LT H P R AC T I C E S TO O B TA I N S U B J E C T I V E I N F O R M AT I O N TO A S S I S T I N H E R A S S E S S M E N T O F H E R S K I N. S H E A S K S H E R , “ D O YO U S P E N D L O N G P E R I O D S O F T I M E S I T T I N G O R LY I N G I N O N E P O S I T I O N ? ” W H I C H O F T H E F O L LO W I N G I S T H E B E S T R AT I O N A L E F O R A S K I N G T H I S QUESTION ? A. To determine the client's risk for pressure ulcers B. To determine the client's risk for skin cancer C. To determine the client's risk for dehydration D. To determine the client's risk for herpes zoster  2. T H E PAT I EN T L O O K S L ET H A R G I C A N D S E EM S SL I G H T LY C O N F U S E D. YO U S U S P E C T T H AT TH E PAT I E N T I S D E H YD R ATE D. W H AT PH YS I C A L F I N D I N G S W O U L D YO U A S S E SS A N D L O O K F O R? S E L E C T A L L T H AT A P PLY. A. Capillary refill B. Heart rate C. Mucus membranes D. Gait E. Pulse  3. YO U P E RF O R M A S KI N A SS E S S M E N T O N A PATI E N T A N D N OT I C E A M O L E. YO U A S K T H E PAT I EN T A B O UT I T. W H I C H O F T H E F O L L OW I N G F I N D IN G S M A KE YO U S U S P E C T F U RTH E R I N V E S T I G AT IO N ? S E L E C T A L L TH AT A P P LY. A. Scabbing and occasionally bleeding B. Change in size C. Feels smooth with touch/palpation D. Dark and uneven  4. A NU RSE M OVES A PEN IN 6 DI REC TIO NS WHI LE WATC HIN G TH E CL IEN T' S EYE MOVEMEN TS. WHI CH TEST IS THE N URSE PERFO RMI NG ? A. Corneal Light Reflex B. Cardinal Fields of Gaze C. Jaeger Test D. PERRLA  5. A N UR S E T E S T S T H E V IS ON O F S EV E R A L CL I EN T S A ND R E C OR D S T H E F I ND I NG. W H I CH F I ND IN G I ND I C AT E S T H E C LI E NT W I T H T H E P OO R ES T DI S TA NT V I S IO N? A. 20/30 B. 20/15 C. 20/50 D. 20/80  6. THE NURSE PERFO RMS THE FO LLOW ING ACTION SHOW IN THE IMAGE B ELOW. WHAT IS THE NU RSE ASSE SSING ? A. Carotid Pulse B. Lymph node C. Skin turgor D. Intercostal spaces  7. TH E NU RSE SHO UL D USE WHI CH O F THE FO L LOWI NG TO A SSESS A CL IEN T’S RISK O F SKIN B REAKD OW N? A. VTE Prophylaxis Algorithm B. Morse Scale C. Braden Scale D. Henrich II HELPFUL INFO  8. W H AT CH A R AC T ER IS T I C OF NA IL C OL OR SH OU LD T H E NU R S E R E CO GN IZ E A S A N IN DI C AT IO N OF H Y P OX IA ? A. Pink B. Cyanotic C. Yellowish D. Greenish  9. A NU R S E OB SE RV E S T H E C LI E NT AT T H E S I DE O F B E D I N T H E P O SI T I ON S H OW N IN T H E I MAG E B EL OW. W H AT H E A LT H P ROB L E MS S H OU LD T H E NU R S E SU S PE C T T H E C LI E NT I S E XP E R I EN CI NG ? A. Asthma B. Heart failure C. Tuberculosis D. Chronic obstructive pulmonary disease  1 0. D U R I N G A H E A LT H S C R E E N I N G E V E N T, T H E N U R S E I S A S S E S S I N G A C L I E N T ’ S R I S K F AC T O R S F O R L U N G C A N C E R. W H E N A D D R E S S I N G T H E M O S T S I G N I F I C A N T FAC TO R F O R L UN G C A N C E R , T H E N U R S E S H O U L D Q U E S T I O N T H E C L I E N T AB O U T W H I C H O F T H E F O L L O WI N G ? A. Childhood exposure to air pollution B. History of tobacco use C. History of working in a factor or smelter D. History of recurrent lung infections  1 1. T H E C L I N I C N U R S E I S T E A CH I N G A YO U N G F E M A LE C O L L E G E S T U D E N T A B O U T T H E R I S K FA C TO R S F O R DE V E L O P I N G B R E A S T C A N CE R I N A N AT T E M P T TO I M P R E S S UP O N H E R T H E I M P O RTA N C E O F D O I N G B R E A S T S E L F - E X A M I N AT I O N S. I N C L UD E D I N T H E T E A C H I N G S H O UL D B E W H I C H O F T H E F O L L OW I N G ? S E L E CT A LL T H AT A P P LY A. Early menarche B. Late pregnancies C. Late menopause D. Young age E. An affected grandmother  1 2. W H I L E I N T E RV I E W I N G A C L I E N T, T H E N UR S E A S K S T H E CL I E N T W H E T H E R S H E H A S E V E R N OT I CE D A N Y L U M P S O R S W E L L I N G I N T H E B R E A S T S. W H AT OT H E R A R E A A S S O CI AT E D W I T H T H E P O S S I B L E R I S K F O R B R E A S T C A N C E R S H O U L D S H E A S K A B O UT R E G A R D I N G T H E P R E S E N CE O F LU M P S O R S W E L LI N G ? A. Underarm B. Neck C. Abdomen D. Shoulder  13. A NU RSE I S I NSPEC TIN G A CL IEN T’S NI PPL ES. W HIC H OF THE FO L LOWI NG FIN DI NGS SHO UL D THE N URSE REGARD A S A C AU SE FO R C O NC ERN ? A. Nipples that have been flat for many years B. Supernumerary nipples C. Nipples that are equal in size D. A recently retracted nipple that was previously everted  14. DURIN G AU SCU LTATI ON O F THE H EART, TH E N URSE N OTES A SWO O SH ING SOU ND, THE N URSE WO U LD D OC UM ENT THIS A S W HAT? A. Murmur B. Extra sound C. Vibration D. Flutter  1 5. T H E NU R SE P R E PA R E TO P E R F OR M A C A R D IOVA S CU LA R E XA MI NAT IO N/ T H E NU R S E U ND ER S TAN DS T H E C OM PO NE NT S O F T H I S E XA MI NAT IO N I NC L UD E ? A. Examining the face B. Examining the neck C. Inspecting and palpating the precordium D. Inspecting the hands and lower legs E. Auscultating the lungs  16. A NU RSE I S OB SERVI NG A STUD EN T A SSESS A C LI ENT’S C A PI LL ARY REFI LL. W HIC H AC TIO N B Y THE STUDENT IN D IC ATES PRO PER TEC HN IQ UE? A. Student gently compresses the wrist area on the side of the thumb B. Student compresses the client’s nail bed until it blanches C. Student applies firm pressure to the hand, noting any indentation D. Student asks the client to turn hands slowly over and back  17. WHICH IS NOT A S/S OF ARTERIAL INS UFFICIENC Y? A. Pt reports sharp, constant pain B. Absent or diminished pulses C. Edema D. Dependent rubor  1 8. T H E N U R S E P R E PA R E S TO A S S E S S A C L I E N T ’ S C A ROT I D A RT E R I E S. W H I C H T E CH N I Q U E S H O U L D T H E N U R S E U S E D U R I N G T H I S A S S E S S M E N T ? S E L E C T A L L T H AT AP P LY. A. Place in the supine position B. Palpate the carotid pulse first C. Place in high-Fowler position D. Auscultate the carotid pulse first E. Ask to hold the breath during the auscultation  1 9. T E M P O R A RY H E A RT PA I N , R E S O LV I N G I N L E S S T H A N 2 0 M I N U T E S , AG G R AVAT E D B Y P H Y S I C A L AC T I V I T Y A N D S T R E S S I S K N OW N A S W H AT ? A. Angina B. Myocardium C. Appendicitis D. Tachycardia  20. THE N URSE IS PREPA RING TO A SSESS A C LI ENT' S A PIC A L IMP UL SE. THE N URSE WO UL D PAL PATE AT W HIC H LO C ATIO N? A. Second intercostal space, left sternal border B. Third intercostal space, left axillary line C. Fourth intercostal space, left sternal border D. Fifth intercostal space, left midclavicular line ATI QUIZ CREATION THANK YOU AND HAPPY STUDYING Email us with any questions: [email protected] [email protected]