NUR 2092 Health Assessment Exam 2

NUR 2092 Health Assessment Exam 2 If you are doing a cardiovascular assessment and you are hearing a bruit/swooshing sounds in the patients carotid artery, what does this mean? Correct Answer: Narrow vessel (Most likely filled with plaque buildup) If you are doing a Snellen eye exam from 20 feet away what are you testing? Correct Answer: Farsided eye sight What are 4 things that the skin does? Correct Answer: Prevention of penetration, temperature regulation, absorbs Vitamin D and wound repair (repairs itself) What cannot the skin do? Correct Answer: Prevent the loss of fluids When you are doing a lung assessment you should listen from what direction to what direction? Correct Answer: Right to left What is the Jaeger card used for? Correct Answer: Testing nearsided eye sight If a mole on a patients skin has abnormal pigmentation and is itchy, at what size does the mole become suspicious? Correct Answer: 6 mm What are you listening for when listening to bowel sounds? Correct Answer: Gurgling If you do not hear any sounds after 1 minute of listening to bowel sounds, what do you do? Correct Answer: Listen for 4 more minutes for a total of 5 minutes. What is a hypoactive bowel sound? Correct Answer: A distant bowel sound (Likely constipation. Only hearing gurgles every 1-2 minutes) What is an indication if a patient has yellow skin? Correct Answer: Jaundice. A liver problem If you are palpating lymph nodes in front of the ear, what lymph nodes are you palpating? Correct Answer: Preoricular If you are doing an abdominal assessment and you only heat a few gurgles every 1-2 minutes, what should you suspect is going on with the patient? Correct Answer: Constipation What should you always ask a patient when doing an abdominal assessment? Correct Answer: When was your last bm (No bm in 3 days indicates constipation) What is cyanoisis? Correct Answer: No oxygen exchange Which of the following patients would take highest priority: Jaundice yellow skin, Pale skin and vomiting or Cyanotic? Correct Answer: Cyanotic (Patient is not getting proper amounts of oxygen exchange) What are some good assessment questions to ask someone that may be having an allergic reaction? Correct Answer: Have you been using any new soaps, lotions, detergent, etc. When assessing radial pulses, what is it important to do? Correct Answer: Assess one side to the other (Should feel both sides at same time to compare) What sounds will you hear while doing a lung assessment on a patient with an upper airway obstruction? Correct Answer: Stridor. This is an upper airway emergency! When resulting a TB skin test what would you be looking and feeling for if it was irregular? Correct Answer: Red, raised bump/wheal. Greater than 5mm is positive, pink patches What sounds will you hear while doing a lung assessment on a patient with a lower airway obstruction? Correct Answer: Wheezes How long should the skin take to turn back to pink when assessing capillary refill? Correct Answer: Less than 3 seconds (2 seconds or less) If capillary refill takes more than 2 seconds to turn from pink to white, what is this called? Correct Answer: Sluggish or slow If capillary refill takes less than 2 seconds to turn from white to pink, what is this called? Correct Answer: Brisk If doing an assessment you notice that the patient tonsils are touching their uvula, is this an abnormal or normal finding? Correct Answer: Abnormal (Tonsillitis) What should you do if you are testing a patients hearing acuity and gross hearing ability? Correct Answer: Have patient shut their eyes to hear better and so that they cannot see your hands. Rub your fingers next to their ear to assess. The patient must verbalize that they hear the sound of your fingers rubbing together. What order do you assess bowel sounds? Correct Answer: Look, listen, then feel/palpate Why must you listen to bowel sounds before palpating? Correct Answer: Always listen before touching because when you palpate, you can move things around in the abdomen and get a false assessment if listening right after. Which heart sound is the loudest? Correct Answer: S1 Where do you hear S1 heart sounds? Correct Answer: On the right side of the chest, 2nd intercostal space. What are you hearing when listening to S1? Correct Answer: Closure of AV valves. Mitral and biscuspid. Lub sound Where do you hear S2 heart sounds? Correct Answer: On the left side of the chest, 2nd intercostal space. What are you hearing when listening to S2? Correct Answer: Closure of SL valves. Aortic and Pulmonic. Dub sound Where can you hear both S1 and S2? Correct Answer: Erbs Point. Left side of chest, 4th intercostal space What are the 2 phases of the cardiac cycle? Correct Answer: Systole and Diastole In order to feel a patients carotid pulse, where must you feel? Correct Answer: Right by the SCM on the side of the neck. Do NOT feel both sides at the same time. When you are assessing a patients lung sounds, where are normal bronchovascular breath sounds heard? Correct Answer: Next to sternal border If a patient is SOB and cannot breathe while in a lying position what does this patient have? Correct Answer: Orthopnea How should a patient with orthopnea be positioned? Correct Answer: Sitting up with their arms up. (Tripod position) This expands their lungs to make breathing easier. What should you do if you feel an irregular radial pulse? Correct Answer: Listen to an apical heart rate for 1 full minute When doing a thoracic assessment what do you look for first? Correct Answer: Look for chest movement. Make sure that chest is expanding symmetrically. When you are percussing a patients back at the costoverterbral angle, what are you checking for? Correct Answer: Kidney tenderness What is it called when a patient is sitting upright and their jugular vein is enlarged? Correct Answer: Jugular Vein Distention (JVD) What does it mean if a patient has Jugular Vein Distention (JVD)? Correct Answer: Increased blood volume, generally congestive heart failure If you are doing a lung assessment and you hear a continuous high pitch squeaking on inspiration or expiration, what does this indicate? Correct Answer: Wheezes What patients are at the greatest risk for developing hypertension? Correct Answer: Obese (men) and Diabetics What kind of sound would you hear if auscultating a heart murmur? Correct Answer: Raspy sounds, like a blowing or "wooshing" sound