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Ch. 26 Terms in this set (105)Which technique of assessment provides the greatest amount of information about the thyroid gland? Palpation Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present? Crackles _______________ are described as bubbling- or popping-type sounds that are usually audible during inspiration Crackles _____________ are typically musical in tone and continuous. Wheezes __________________ are high-pitched and shrill-sounding breath sounds that occur when the airway becomes narrowed. (they have a musical quality to them). Sibilant wheezes These are the typical wheezes heard when listening to an asthma patient. Sibilant A ______________________ is an added sound with a musical pitch occurring during inspiration or expiration, heard on auscultation of the chest and caused by air passing through bronchi that are narrowed by inflammation, spasm of smooth muscle, or presence of mucus in the lumen sonorous wheeze A ______________ is a continuous, grating-type sound. friction rub When percussing the liver, the sound should be: Dull Percussion of the abdomen is _____________ tympanic hyperinflated lung tissue is _______________ hyperresonant normal lung tissue is ____________, and bone is flat. resonant Normal findings of the internal eye structures include: a uniform red reflex; round white or pink optic nerve disc; reddish retina; and bright-red arterioles and dark-red veins. Visual problems with close objects occur more frequently after the age of _______. 40. The sequence of techniques used to assess the abdomen is: inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. _______ is the fullness or elasticity of the skin Turgor Poor skin turgor is a sign of _______________. Dehydration When the client is dehydrated, the skin's ___________ is decreased, and the skin fold returns slowly. elasticity What percentage of weight change in 6 months is considered abnormal? 10% A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? Crepitus or crepitation Which part of the hand is best for sensing temperature? the dorsum Which part of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur? The palm of the hand Which part of the hand is concentrated with nerve endings and can sense fine difference in texture and consistency? The fingertips The Glasgow Coma Scale (GCS) evaluates three key categories of behavior: eye opening, verbal response, and motor response. Within each category of The Glasgow Coma Scale, each level of response is given a numerical value. The maximal score is _____ indicating a fully awake, alert, and oriented client. 15 Which components are included in the integumentary system? Skin Soft, low-pitched, whispering sounds are ____________ sounds heard over most of the lung fields. normal Inflammation of the _______ would result in a friction rub pleura Performing a __________________________________ includes asking about the physical limitations or abilities that a client may experience such as how the client is able to manage transportation, bathing, medication administration, and dressing functional assessment Coping with stressors would be included in the __________________________ assessment as well as the use of alcohol, tobacco, and illicit drugs. psychosocial/lifestyle Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as: ptosis.
Inward turning of the lower eyelid is termed ____________ entropion Outward turning of the lower lid is termed ____________ ectropion ___________ is constriction of the pupil, which is often caused by medications. Miosis When a client enters the acute care facility, the nurse should perform a: Comprehensive health assessment A ___________________________________ encompasses the physical, psychological, social, and spiritual dimensions of living. comprehensive health assessment The nurse is preparing to assess a client's abdomen. Arrange the steps of the assessment in the correct order. Inspection The nurse is palpating a client's precordium. Which result is an expected clinical finding? Palpable pulsation over the mitral area (apical pulse) Romberg test assesses_____________; an unsuccessful test constitutes a likely risk for ______. Balance Falls ____________ is broad and includes a complete health history and physical assessment. A Comprehensive Health Asessment A comprehensive assessment includes: cognitive, psychosocial, and emotional development in addition to physical growth _________, redness of the skin, is caused by dilation of superficial blood vessels. It is associated with sunburn, inflammation, fever, trauma, and allergic reactions Erythema ___________is a collection of blood in the subcutaneous tissues, causing purplish discoloration. Ecchymosis Hair is found on all body surfaces except: the palms of the hands, the soles of the feet, and parts of the genitalia. Inspection and palpation of the _____________ area can detect enlarged lymph nodes. supraclavicular Describe the normal signs of aging you might find in a physical assessment: Decreased near
vision (presbyopia), A nurse is completing a vision exam with the Snellen eye chart, what do the numbers mean? Such as 20/30? The first number indicates the distance the person is standing from the chart; the second number gives the distance at which a normal eye can see it. Asking the client to explain the meaning of a common proverb allows the nurse to assess the client's ______________. abstract reasoning Asking the client to repeat three objects that the nurse told the client earlier in the interview assesses _______________ recent memory. The nurse needs to ask a question that may be corroborated to confirm a __________________. past or remote memory This is the initial assessment after a spinal cord injury; therefore, it would be the top priority to help determine the degree of injury by assessing for reflexes. Reflexes When a client enters the acute care facility, the nurse should perform a _____________ assessment. Comprehensive A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living. To assess a client's visual accommodation, the nurse has the client: look at a close object, then at a distant object. To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the: mastoid process. Which statement accurately represents a characteristic of the third heart sound? S3, the third heart sound, is considered normal in children and young adults and abnormal in middle-aged and older adults. Which statement accurately represents a characteristic of the fourth heart sound? S4 is represented by "dee-lub-dub" and is considered normal in older adults but abnormal in children and adults. Which is the most reliable early indicator of infection in a client who is neutropenic? Fever The nursing student is selecting a blood pressure cuff prior to obtaining a patient's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading? 40% of the circumference of the limb to be used Cardiac output is determined by multiplying _____ by _____. the stroke volume by the heart rate/minute. The nurse should question an order to administer the medication rectally if the child has a diagnosis of ______ or ______, because of the increased risk of infection and bleeding that may result from tissue trauma. Thrombocytopenia or neutropenia Assessing an oral temperature with a _______________ is contraindicated in unconscious, irrational, or seizure-prone adults as well as in infants and young children because of the danger of breaking the thermometer in the mouth. glass thermometer A mild elevation in body temperatur might indicate a serious infection in (WHICH AGE GROUP), who do not have well-developed temperature control mechanisms. infants younger than 3 months of age Cranial nerve _____ controls the muscles of the face. VII
Swallowing and speaking is demonstrated with cranial nerve ___. X Cranial nerve ____ is assessed with movement of the tongue. XII The movement of shoulder muscles assesses cranial nerve ____ XI The nurse testing a client's eyes asks the client to focus on a finger from 60 cm away and moves the client's eyes through the six cardinal positions of gaze. Using this procedure, which cranial nerves is this nurse testing? III: Oculomotor Newborns and children use _____________ to breath as opposed to adults, who use the _____________. abdominal muscles, thoracic muscles. Increased ___________________ of the chest is seen in older adults. anteroposterior diameter Having an increase in the dorsal spinal curve (kyphosis) is seen in which age group? older adults. Newborns and children have __________ breath sounds and a ________ respiratory rate than adults. Louder & higher respiratory rate Older adults have __________ thoracic expansion. decreased The nurse is preparing to assess a client's abdomen. Arrange the steps of the assessment in the correct order: Inspection The first subject discussed in a client interview is the client's specific reason for seeking care. The subject is often called the ______________. The client's chief complaint or chief concern. ________ occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel. Bruits While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds? moisture in air passages _____________ are fine-to-coarse "" sounds made as air moves through wet secretions. They are described as "fine" when air passes through moisture in small air passages and as "coarse" when air passes through moisture in the bronchioles, bronchi, and trachea. Crackles ________ is a harsh inspiratory sound that can sound like crowing. It may indicate an upper airway obstruction Stridor __________ is a vibration felt on the client's chest during low frequency vocalization. Fremitus A _________ is a whistling or rattling sound in the chest as a result of obstruction or narrowing in the air passages. wheeze When using assessment equipment that will touch the client, what should the nurse do before conducting the assessment? Warm the equipment with hands or warm water. A nurse assesses a client's eyes by testing the cardinal fields of vision for coordination and alignment. Which eye characteristic is being assessed by this process? extraocular movements While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these? bronchovesicular A ________________ assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. comprehensive assessment How do you convert lbs to kgs? divide by 2.2 A nurse is percussing a client's abdomen. Which finding would the nurse document as normal? Tympany What is the noted difference between the sims and a lateral position? The clients dependent arm is behind their back and not underneath them or in front of them. Indirect auscultation uses ______ to auscultate. Stethescope
When using percussion, the muscle and bone will sound ______. Flat When using percussion, a normal lung will sound ______. Resonate When using percussion, organs such as the liver will sound ______. dull Direct auscultation uses ______ to auscultate. Naked ear What equipment is needed to perform a physical exam? Watch with a second hand The student nurse is assigned to care for a 65 year old client with a diagnosis of myocardial infarction. The
student knows that to assess the circulatory system they will need to assess: (check all that apply) A.Palpation of pulses D.Skin color Skin dryness is not part of the cardiovascular assessment. A first semester nursing student is in the nursing lab to practice performing a physical assessment. During the cardiovascular assessment the student knows they should assess an apical pulse for which of the following: (choose all that apply) C, D & E Rate, rhythm and regularity.
Define Striae Stretch marks If unable to locate the client's popliteal pulse during a routine examination, the nurse should perform which of the following next? Check for a pedal pulse. A.If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located. How do you test immediate recall? Have the patient recall a series of numbers. How do you test remote (long-term) memory? Have the pt recall childhood events How do you test short-term memory? Ask the patient to tell you how they got to this location (includes events of the current day) How do you test attention span and calculation skills? Have the pt subtract backwards from 100 Define Thrombocytopenia low platelet count Which age-related changes increase the risk for complications after illness or injury in the older adult? -Decreased skin elasticity Which subjective questions by the nurse demonstrate a familiarity with commonly occurring disorders that can put an older patient at risk for unnecessary iatrogenesis? -How well do you usually sleep? REMEMBER SPICES! The essential elements that a fall risk tool should assess are: Symptoms of dizziness, high risk medications, Mental and emotional status, altered elimination, mobility and male gender. Sets with similar termsPrepU: Health Assessment57 terms laura_howard20 Health Assesment Ch.2522 terms quizlette938304 N206 Exam 3 CoursePoint--Assessment74 terms amyvn Sets found in the same folderVital Signs - Thermoregulation51 terms AshleyHamel918 Vital Signs- Pulse & Blood Pressure38 terms AshleyHamel918 Vital Signs- Respirations & Vsim questions32 terms AshleyHamel918 Things to make into flashcards /study when I get h…9 terms AshleyHamel918 Other sets by this creatorCANCER PrepU | Test 7 | Hinkle Ch. 1514 terms AshleyHamel918 Inflammation {Part II}12 terms AshleyHamel918 Perioperative Nursing | Inflammation24 terms AshleyHamel918 Immune Function | Hypersensitivity | Rhe…33 terms AshleyHamel918 Other Quizlet setsMosby's Practice Test: Two29 terms kkojadin Forensics CH 846 terms ekyoder i don't care about the title20 terms trschumacher RPHS Modern History/Pioneers Review42 terms RidgePointRoyals Which technique of assessment provides the greatest amount of information about the thyroid gland?Ultrasound is the primary study by which the thyroid gland is imaged.
When performing an abdominal assessment the nurse uses a different order of techniques than with other systems which of the following represents this order?Terms in this set (5) What is the correct order for abdominal assessment? Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, palpation. Palpation is the last step in abdominal assessment.
What percentage of weight change in 6 months is considered abnormal?But many health care providers agree that a medical evaluation is called for if you lose more than 5% of your weight in 6 to 12 months, especially if you're an older adult. For example, a 5% weight loss in someone who is 160 pounds (72 kilograms) is 8 pounds (3.6 kilograms).
When a client enters the acute care facility the nurse should perform a?When a client enters the acute care facility, the nurse should perform a: comprehensive health assessment. A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol use.
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Which technique of assessment provides the greatest amount of information about the thyroid gland quizlet?
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