NUR 3314 Health Assessment KAHOOT PDF

NUR 3314 Health Assessment KAHOOT IN DEPTH REVIEWS Which statement represents subjective data? Patient denies pain When should you perform a complete mental status exam? When there has been recent behavior change (if it says only, it's probably not right, not every only when appropriate) A pati...

NUR 3314 Health Assessment KAHOOT IN DEPTH REVIEWS Which statement represents subjective data? Patient denies pain When should you perform a complete mental status exam? When there has been recent behavior change (if it says only, it's probably not right, not every only when appropriate) A patient's affect tells the nurse what information? Mood When assessing the radial pulse, we count for 30 seconds then multiply x 2 if the pulse is irregular T Or F (False) IF irregular count for 60 seconds Stroke volume is Pulse force (BPM Is Rate) Regularity is rhythm (force how much blood coming out with each heart beat) Systolic blood pressure measures the heart when it contracts at rest is diastolic A bulla is larger than 1cm superficial and thin walled TRUE A papule is solid, elevated and less than 1 cm in diameter (True) A wheal is superficial, raised, transient, and irregular (true) It is correct technique when assessing skin temperature to use which of the following? dorsal (back) aspect of your hand Sleeping, bracing, and rubbing are signs of which type of pain (chronic) What you observe as a nurse is the best indicator of your patient's pain (false) what the patient tells you (pain is subjective) Asking the patient to describe their pain in their own words assess which of the following? Quality of pain A cuff that is too large for your patient will yield a BP that is too high (false, too small) Dopplers are used when you cannot feel your patient's pulse (true) Pallor is best assessed where on our patients buccal mucosa When interviewing patients why questions may make the patient defensive When assessing your patient's judgement, it is best to make up hypothetical scenario to see what they would do? false ABCD mnemonic stands for which of the following during a skin assessment Asymmetry, border regulation, color, diameter Which of the following is an example of acute pain? Appendicitis The older the patient is the less you need to worry about their pain. false An indicator of poorly controlled acute pain may be indicated by which of the following? increased pulse (increase in vital signs) An 89-year-old tongue would be smooth in appearance. Truth A patient has an abnormal lab level, what priority level is the patient? second level priority Confrontation assesses which of the following? Peripheral Vision (it assesses peripheral vison because in book 291 when you hold an index card over there eye and ask if they can see your finger.) Accommodation assesses for which of the following? Pupillary contraction eyes should track the pen follow the eyes with the pen light for good near vision" Spirituality is a broad term focused on a connection with something bigger than oneself? True Religion and spirituality are the same. False A 90-year-old male patient will normally experience which of the following related to hearing loss? High pitched frequency is harder to hear Does your family have a history of cancer is an example of a question about your patients' health beliefs? False (health history) Health belief is end of life care, reg trips to doctor, dentist etc. All of the following are true about vital signs in an aging adult except which of the following? More likely to develop fever The width of the BP cuff bladder should equal 40% of the armed circumference. True The nurse checks for orthostatic hypotension by taking BP\'s lying down only. False (lying sitting and standing) Which of the following is a normal vital sign for an athlete at rest? HR 44 BPM (the more we exercise the less the heart beats due to strength.) Pulse pressure is the difference between systolic and diastolic blood pressure. true Which of the following is a normal finding in the skin of an agent adult? Loss of elastin as we age, we loss sweat glands, poor turgor Which of the following is a part of a general survey? Body stature Which of the following is the normal range for your patients' pulse? 50-95 Inspection includes which of the following: looking at the shape of the body part. Which patient should the nurse assess first? A 50-year-old male complaining of chest pain Where the lymph nodes most palpable? The head and the neck are where they are most palpable A nurse assesses a patient who is hard of hearing what technique would facilitate the patients hearing? Turn off the, tv face the patient when talking, speak slower when talking to the patient A patient presents with gunshot wounds he can communicate but is losing blood what is the best way for the RN to assess? Ask questions about health history while stopping the bleeding The nurse asked the patient to raise her eyebrows to test what cranial nerve? CN VII Facial (smile, frown, raise eyebrows) You are a patient has heart failure. Abnormal findings might include which of the following? Select all that apply. Elevated heart rate, lower extremity edema, orthopnea What does a DVT look like? Unilateral swelling in the leg that is red warm to the touch and tender. Upon assessment will tell the patient that you hear a bruit: a bruit sounds like a swishing sound because of turbulent blood flow Upon assessment, you notice a heave, explain to the new graduate nurse that a heave is Felt as a lifting impulse system at the left lower sternal border, and abnormal finding that is caused by right ventricular enlargement. When assessing your patient, you notice it through in the precordium, assess this by? Palpation. "A feel for a thrill" A patient has an S2 split when the nurse listens to the heart sounds. This is as associated with? Inspiration. When auscultating the precordium, the aortic and pulmonic valve closures are normally heard during? S2 You are asked which hearts are normal findings in a 18-year-old male are normal finding: pulse that changes upon expiration and inspiration An S3 sound may be normal and what population? Those under the age of 35 A s3 heart sound heard in a 55-year-old can be indicative of heart failure? True Patient arrives at the ED complaining of flank pain. The nurse assesses the patient by checking for: checking for costovertebral angle tenderness (CVA) After listening for one minute, you have not heard any audible bowel sounds. what should you do next? Continue listening for four more minutes to determine bowel sound status. Your patient has an abdominal pulsation and history of smoking a pack of cigarettes a day, The nurse might suspect. an aortic aneurysm (is pulsating) What do you assess when inspecting the anterior chest of a patient (SATA)? Shape of chest wall and configuration of the chest wall. What lung sounds would the nurse expect to hear when assessing an asthmatic patient? Wheezes A patient resting RR of 36 is a normal finding. FALSE it should be between 16-25 What is the best way for the patient to position for a breast exam? Ask the patient to raise their hands above their heads. (In supine) What area of the breast is more likely to have tumors? Upper outer quadrant What breath sound is a normal finding? Bronchovesicular During an abdominal assessment you auscultate a hollow drum like sound in the patients abdomen this sound is: tympany and should predominate all 4 quadrants What is the correct order of an abdominal assessment (IAPP) Inspection, Auscultation, Percussion, Palpation. A woman presents to the ED with severe abdominal pain holding her right side. An assessment should include: palpating for rebound pain in the right lower abdominal quadrant. Auscultate the patient's bowel sounds A normal triglyceride is \< 150. The nurse firmly strokes upon the medial aspect of the knee two or three times to displace any fluid. This is? Testing for a bulge sign. You are assessing your patients, muscle strength you will document on a grading scale that rates from? 0-5. The part of the brain that coordinates movement, maintains equilibrium, and posture is the? cerebellum. In older ad with Parkinson's might present with which of the following: hunched posture and pin, rolling finger movements. You noticed that your patient is unable to touch her finger to her nose during your assessment. You might suspect: cerebellar dysfunction Why would a patient be asked to clinch their teeth while performing a DTR assessment? The patient needed a reinforcement distraction technique The Glasgow coma scale is an assessment tool that measures consciousness you know that: the GCS is a reliable tool to assess neural responsiveness. The higher the score the more alert the patient is. Upon assessment, you know patient has a reactive right pupil 3 mm, left pupil 6 mm and non-reactive, findings suggest? Cranial nerve three: occur motor dysfunction, patient has a right sided brain injury. Cranial nerve XI (accessory nerve) is assessed by doing which of the following? Lifts shoulders against resistance. A patient has a positive Romberg sign when they sway when their eyes are closed and feet parts together: true Tricep reflex causes flexion in the forearm: false (extension) Unexpected finding following in mastectomy might include which of the following: Lymphedema. Normal capillary refill is less than three seconds: true 1+ / (0-4 scale) is the correct way to document which kind of edema: mild pitting edema. Which of the following reflexes are normal in the adult population: Plantar, PERRLA, Achilles. Which of the following is an effective way to help patients with their breast health? Teach BSE Hinge joints demonstrate, which of the following motions: extension and flexion. Diabetic peripheral neuropathy might include which of the following signs/symptoms: decreased sensation in lower extremities, tingling or stinging feeling in the soles of the feet & injuries to the soles of the feet. First level priority problems might include: patients with problems related to airway, breathing, and circulation. A patient with a PO2 of 88%. A patient is admitted with a diagnosis of right sided embolic, temporal lobe stroke, the nurse would expect to find: incomprehensible speech, and impaired taste and smell. During abdominal assessment, the examiner would expect to hear tympany and dullness with percussion: true The following activities would be considered third level priorities: discharge teaching providing a walker post hip surgery. Increased bone density is an indication of osteoporosis: false (decreased) The nurse knows they would be able to assess a patient's liver and gallbladder in: the right upper quadrant of the abdomen. The S1 is heard loudest at the Apex.: true The S2 is heard loudest at the base: true Adduction is moving a limb toward the midline of the body: true Abduction is moving a limb away from the midline of the body: true \_\_\_ is demonstrated as bending a limb at a joint: flexion A scaphoid abdomen caves inward when observed during the inspection of the abdomen: true What is the S1 sound? Beginning of systole What group is at highest risk for hypertension in the US? African-American A well healed scar from an appendectomy.: normal, should be documented on skin assessment. A normal radial pulse would be charted as: +2 The nurse places the stethoscope at what place so here the S1 sound the loudest? Fifth intercostal space and midclavicular line. What node is the pacemaker of the heart? (sinoatrial) SA node. A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles: true Abdominal ascites is: presence of fluid Which of the following is defined as difficulty swallowing medications and food: dysphasia What is hepatomegaly? Enlarged liver. Osteoporosis is the loss of bone density: true How would the nurse chart crunching or grading sound in the right knee joint: crepitation Decerebrate rigidity is a very ominous condition and may indicate a brain injury: true What is a sign of increased intracranial pressure? A sudden, unilateral, dilated, and non-reactive pupil A Glasgow Coma Scale finding \