NUR2092 Health Assessment Exam 2 Questions and Answers for .

NUR2092 Health Assessment Exam 2 Questions and Answers for NUR2092 Health Assessment Exam 2 Questions and Answers () If you are doing a cardiovascular assessment and you are hearing a bruit/swooshing sounds in the patients carotid artery, what does this mean? -Narrow vessel (Most likely filled with plaque buildup) If you are doing a Snellen eye exam from 20 feet away what are you testing? -Farsided eye sight What are 4 things that the skin does? -Prevention of penetration, temperature regulation, absorbs Vitamin D and wound repair (repairs itself) What cannot the skin do? -Prevent the loss of fluids When you are doing a lung assessment you should listen from what direction to what direction? -Right to left What is the Jaeger card used for? -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? -6mm What are you listening for when listening to bowel sounds? -Gurgling If you do not hear any sounds after 1 minute of listening to bowel sounds, what do you do? -Listen for 4 more minutes for a total of 5 minutes. What is a hypoactive bowel sound? -A distant bowel sound (Likely constipation. Only hearing gurgles every 1-2 minutes) What is an indication if a patient has yellow skin? -Jaundice. A liver problem If you are palpating lymph nodes in front of the ear, what lymph nodes are you palpating? -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? -Constipation What should you always ask a patient when doing an abdominal assessment? -When was your last bm (No bm in 3 days indicates constipation) What is cyanoisis? -No oxygen exchange Which of the following patients would take highest priority: Jaundice yellow skin, Pale skin and vomiting or Cyanotic? -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? -Have you been using any new soaps, lotions, detergent, etc. When assessing radial pulses, what is it important to do? -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? -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? -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? -Wheezes How long should the skin take to turn back to pink when assessing capillary refill? -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? -Sluggish or slow If capillary refill takes less than 2 seconds to turn from white to pink, what is this called? -Brisk If doing an assessment you notice that the patient tonsils are touching their uvula, is this an abnormal or normal finding? -Abnormal (Tonsillitis) What should you do if you are testing a patients hearing acuity and gross hearing ability? -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? -Look, listen, then feel/palpate Why must you listen to bowel sounds before palpating? -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? -S1 Where do you hear S1 heart sounds? -On the right side of the chest, 2nd intercostal space. What are you hearing when listening to S1? -Closure of AV valves. Mitral and biscuspid. Lub sound Where do you hear S2 heart sounds? -On the left side of the chest, 2nd intercostal space. What are you hearing when listening to S2? -Closure of SL valves. Aortic and Pulmonic. Dub sound Where can you hear both S1 and S2? -Erbs Point. Left side of chest, 4th intercostal space What are the 2 phases of the cardiac cycle? -Systole and Diastole In order to feel a patients carotid pulse, where must you feel? -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? -Next to sternal border If a patient is SOB and cannot breathe while in a lying position what does this patient have? -Orthopnea How should a patient with orthopnea be positioned? -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? -Listen to an apical heart rate for 1 full minute When doing a thoracic assessment what do you look for first? -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? -Kidney tenderness What is it called when a patient is sitting upright and their jugular vein is enlarged? -Jugular Vein Distention (JVD) What does it mean if a patient has Jugular Vein Distention (JVD)? -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? -Wheezes What patients are at the greatest risk for developing hypertension? -Obese (men) and Diabetics What kind of sound would you hear if auscultating a heart murmor? -Raspy sounds, like a blowing or “wooshing” sound How would you best feel temperature with your hand? -By using the dorsal side of your hand What is a regular apical heart rate for an adult? -60-100bpm What patients are at an increased risk for developing emphysema? -Smokers, COPD patients What is bradycardia? -Slow or decreased heart rate. Less than 60bpm What does the chest of an empysema patient often look like? -A barrel chest What are 3 things that you are looking for when assessing the nose and nasal cavity? -1.Deviation (midline) 2. Patent nares (any swelling) 3. Drainage/discharge Your lymph nodes are not always palpable. What are some examples of when they are palpable? -When sick, or when a person has cancer What is a normal finding of the eyes when a pen light is shined into them? -Pupils dilate when patient is looking at a distant object and light is shined into the eye. If you notice that a patient has a bulge in their abdomen when coughing, what can this indicate? -A hernia. An abnormal finding that should be reported. What is the #1 cause of a UTI? -E. Coli If doing a lung assessment for pneumonia what should you do? -While listening with a stethoscope and doing percussion, have the patient say “E” and if they have pneumonia it will sound like patient is saying “A” What is postpopliteal? -Behind the knee When listening to heart sounds on a healthy adult, where do you listen for an apical heart rate? -Left side of chest, 5th intercostal space mid nipple. Will be heard the loudest here. How would you interpret these results from a Snellen chart test: 20/100 -A patient is seeing at 20 feet what a normal person sees at 100 feet. What is a normal pupil reflex/response? -Both pupils constrict (consensual normal response) What would you see with a normal breast exam? -Nipple and breasts are symmetric. Areola and nipples are normal color, not red or swollen. No dimples in skin. If a patient has liver failure they most often will have a large belly. What is this? -Ascites. Fluid pools in abdomen If a patient is having black and tarry stools what does this indicate? -Upper GI bleed If a patient has blood in their stool, what can this indicate? -Lower GI bleed What is dysphasia? -Difficulty Swallowing If a patient has edema, pooling of blood, varicose veins, reddish brown legs, bleeding, ulcers, and swelling what do they likely have? -Venous insufficiency What are some common signs and symptoms of cirrhosis of the liver? -jaundice, itching What can cause indigestion, nausea, and vomiting? -Fluid buildup If a patient has pale legs, cold limbs, and hair loss what do they likely have? -Arterial insufficiency Is ascites a sign or symptom? -No it is a clinical manifestation What quadrant is the liver in? -Right upper quadrant What is common about venous insufficiency ulcers and what is important to assess? -Usually on the inside of the legs. Looks like a pressure ulcer, but is in a non-pressure spot. Always assess the amount of drainage! What is a risk factor for developing cataracts? -Being over age 70 What are some modifiable risks for developing cancer? -Diabetes, obesity, lack of fiber, alcohol consumption What is the #1 risk for colon cancer? -Blood in stool What are some modifiable risk factors for colon cancer? -Fiber intake, red meat, smokers, exercise What are some risk factors for breast cancer? -Menstrual history, family history What is cystitis? -Inflammation of the bladder. A bladder infection or UTI If you are doing an abdominal assessment and you palpate the abdomen and then release and the patient has tenderness what is likely the cause? -Rebound tenderness. Likely peritoneal irritation (peritonitis/inflammation) What age are mammograms suggested? -Age 45 During an abdominal assessment when you palpate then percuss lower or above the right costal margin what are you feeling? -Feeling the liver If using the bell of your stethoscope on the abdomen, what are you listening for? -Vascular sounds During a lung assessment you hear low rattle sounds, what are you hearing? -Rhonchi If a patient has a cast on and when you are assessing capillary refill it is greater than 2 seconds and the patient’s toes are cold and pale. What should you do? -Remove the cast ASAP When a patient has a cast, what do you have to assess for? -Pulses, sensation, warmth, color, capillary refill and movement If a patient has peritoneal irritation how would you assess for this? -Palpation of the abdomen for rebound tenderness What do the valves in the heart do? -Prevent the backflow of blood Where is the radial artery located? -Thumb side of arm along radius Where is your tibial artery? -Behind ankle along tibia What is Nocturia? -Increased urination at night What are Vesicular breath sounds? -Soft and low pitched with a rustling quality during inspiration and are even softer during expiration. These are the most commonly auscultated breath sounds, normally heard over most of the lung surface. What are Bronchial breath sounds? -Heard over the trachea. Have a higher pitch, are louder, inspiration and expiration are equal and there is a pause between inspiration and expiration. The vesicular breathing is heard over the thorax, lower pitched and softer than bronchial breathing What is lymphedema? -extra fluid Where do you listen for bowel sounds first? -RUQ (Then LUQ, RLQ, LLQ) A-Aortic. Right side of chest 2nd intercostal space P-Pulmonic. Left side of chest 2nd intercostal space E-Erbs Point. Left side of chest 3rd intercostal space T-Tricuspid. Left side of chest Sternal border 4th intercostal space M-Mitral. Left side of chest 5th intercostal space mid clavicular line Radial Pulses: 0 Absent 1+ Weak 2+ Normal 3+ Increased, Full, Bounding Edema: 1+ Mild pitting, slight indentation 2+ Moderate pitting, indentation subsides rapidly 3+ Deep pitting, indentation remains, legs look swollen 4+ Very deep pitting, indentation lasts a long time, legs very swollen ABCDE rule to detect suspicious lesions A: asymmetry B: border C: color D: diameter E: elevation & enlargement What is a Rinne test? -It is used to evaluate the loss of hearing in one ear. The Rinne test differentiates sounds transmitted by air conduction from those transmitted through the mastoid by bone conduction. It quick screens for the conductive hearing loss. Test Bone Conduction 1. Place the vibrating tuning fork on the mastoid process. 2. The patient should be asked to cover the opposite ear with their hand. 3. The patient should report when the sound can no longer be heard 4. Then move the vibrating tuning fork over the ear canal to the ear without touching it. 5. The patient should indicate when air conduction of the sound can no longer be heard. Normal finding: Air conduction should be better than bone conduction, and air conduction should persist twice as long as bone, this is a "positive test." Abnormal: Bone conduction is better than air conduction, this suggests conductive hearing loss and is referred to as "negative test." Annular Lesions are circular Bulla Lesions are a bubble like cavity filled with air or fluid. A type of blister. Clear fluid inside. To be classified as a bulla, the blister must be larger than 0.5 centimeters in diameter. Smaller blisters are called vesicles. Plaque on skin: Plaque psoriasis is a chronic autoimmune condition. It appears on the skin in patches of thick, red, scaly skin. Plaque psoriasis is the most common form of psoriasis.   Pectus excavatum, also known as funnel chest, is a condition whereby an individual’s breastbone, or sternum, grows inwards. This results in a sunken appearance of the chest wall. Confluent Lesion: Zosterform Lesion: Gyrate Lesion: Papule Lesion: