LECTURE 2:CHAPTER 30

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hcperry
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100612
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LECTURE 2:CHAPTER 30
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2011-09-08 21:24:06
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CHAPTER 30 LECTURE
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LECTURE 2:1505:CHAPTER 30 HEALTH ASSESSMENT
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  1. WHAT ARE THE METHODS OF EXAMINING?
    Inspection, Palpation, Percussion, Ausculation
  2. What method is the visual examination of a system?

    A. Palpation
    B. Inspection
    C. Percussion
    B. INSPECTION: Assessing colors, shape, size, symmetry, etc...
    (this multiple choice question has been scrambled)
  3. What method is the process of listening to sounds within the body?

    A. Palpation
    B. Inspection
    C. Percussion
    C. Percussion
    (this multiple choice question has been scrambled)
  4. A pt. comes in and has a bluish tinge, he or she is considered:

    A. Pallor
    B. Erythema
    C. Jaundice
    D. Cyanosis
    D. Cyanotic; Deficient Oxygen Flow
    (this multiple choice question has been scrambled)
  5. A pt. comes in and has a yellowish tinge, he or she has:

    A. Cyanosis
    B. Erythema
    C. Jaundice
    C. Jaundice
    (this multiple choice question has been scrambled)
  6. Changes occur in black skin at an earlier age than in white skin. True or False.
    False
  7. Dry skin is prominent over the extremities.
    TRUE OR FALSE.
    TRUE
  8. A 24 year old woman comes in and has patches of hypopigmented skin. What is this called?
    VITILLIGO
  9. John comes in and his face appears very flushed. What is another term for a very pale and flushed appearance?
    PALLOR.
  10. What is the term for hair loss?
    Alopecia


  11. Which of the following best describes this position?

    A. Supine
    B. Lithotomy
    C. Dorsal Recumbant
    D. Prone
    C. DORSAL RECUMBANT

    Back Lying Postiion with knees flexed and hips rotated, small pillow under the head and soles of feet on the surface.
    (this multiple choice question has been scrambled)


  12. Which of the following best describes this position?
    A. Dorsal Recumbant
    B. Supine
    C. Lithotomy
    D. Prone
    B. Supine; Back-lying position with legs extended; with or without pillow under the head. Used to assess head, neck, lungs, heart, vital signs, pulses, etc...
    (this multiple choice question has been scrambled)



  13. Which of the following best describes this position?
    A. Sims
    B. Prone
    C. Supine
    D. Dorsal Recumbant
    A. Sims; Side lying position with lowermost arm behind the body, uppermost leg flexed at hip and kneww, upper arm flexed at shoulder and elbow. Used to assess rectum and vagina.
    (this multiple choice question has been scrambled)
  14. What word also means nearsightedness?
    Myopia
  15. Farsightedness
    Hyperopia
  16. SELECT ALL THAT APPLY

    IN OLDER ADULTS

    1. Changes in white skin occur at an earlier age than in black skin.

    2. Clients tend to be "dumber" as they age.

    3. Dry skin is prominent in the extremities.

    4. The hair begins to thin
    1, 3, 4.

    Refer to Chapter 30 & Lecture 2 Notes
  17. Uneven Curvature of the Cornea
    Astigmatism
  18. PROTRUSION OF THE EYEBALLS WITH ELEVATION OF THE UPPER EYELIDS
    Exopthalmus
  19. What is the medical term for enlarged pupils?
    Mydriasis;
  20. What is the medical term for constricted pupils?
    Miosis
  21. A patient comes in with unequal pupils and crossed eyes, what is the medical term for each?
    • Aniscoria; Unequal Pupils
    • Strabismus: Cross eyed
  22. Describe one and two point discrimination?
    The ability to sense whether one or two areas of the skin are being stimulated by pressure.
  23. What is the act of recognizing object by touching and manipulating them?
    Stereognosis
  24. When doing a neurological assessment on a pt, what is an effective way to recall immediate recall?
    Ask the client to repeat a series of three digits. 7-3-4
  25. When doing a neurological assessment on a pt, what is an effective way to assess recent memory
    • Ask the client to recall the recent events of the day.
    • Provide the pt with a color, object, and address and ask the client to repeat later in the interview.
  26. Which Cranial Nerve functions for smell?
    Olfactory
  27. Which cranial nerve functions for moving the eyeball downward and laterally?
    Trochlear
  28. If a nurse is assessing a pt with edema and the measurement she/he receives is 6mm, what is the grade of the edema?
    +3
  29. Define an excoriation
    Scratches, some chemical burns.

    pp.588
  30. SELECT ALL THAT APPLY

    An elderly patient's living conditions in a LTC facility or hospital should include which of the following?


    1. No creases in the elderly's bed.
    2. Giving the patients meds that makes them happy.
    3. Using soft linen and towels
    4. Making sure the pt. is comfortable
    1, 3, 4
  31. Is tenting of 5 seconds acceptable? Why or why not?
    Tenting is used to assess the turgor of a patient's skin. The skin's elasticity can change due to aging and dehydration, therefore tenting should be < 3 seconds.
  32. Is assessing turgor on the forehead of the elderly acceptable?
    Yes
  33. How do you complete a skin assessment on a dark skinned patient?
    Check the mucous membrane to check oxygenation; It should be pink and moist.

    The hands should be pink.

    Check for pallor of the mucous membrane
  34. Explain what conductive hearing loss means.
    When a pt. has a physical obstruction of sound waves due to obstruction by rocks, wax, foreign objects, etc...
  35. Explain what sensioneural hearing loss is?
    Caused from a cochlear defect of the 8th cranial nerve, brain abnormalities, or from loud music.
  36. When assessing the pharynx, trachea, and larynx what are some methods nurses use?
    Visually assess the uvula, and look for drainage from sinuses

    Palpate the trachea for position & tenderness

    Assess for voice hoarseness
  37. Nurse Betty is assessing Mr. Phil and notices that he has fine, short, interrupled sounds best heard on inspiration. Explain what she hears, and what is causing it.
    Crackles, rales; Caused by air passing through fluid or mucus in any air passage.
  38. Nurse Betty is assessing Mrs. Young and notices that she hears superficial grating or creaking sounds heard during inspiration and expiration. Explain what she hears, and what is causing it.
    Friction Rub; Rubbing together of inflamed pleural surfaces.
  39. If unable to locate the client's popliteal pulse during a routine examination, what should the nurse perform next?

    1. Check for pedal pulse
    2. Check for a femoral pulse
    3. Take the client's B/P on that thigh
    4. Ask another nurse to try to locate the pulse.
    Check for a pedal pulse

    • p.1533
    • Chp. 30-#4
  40. Which is a normal fiding on auscultation of the lungs?
    1. Tympany ver the right upper lobe.
    2. Resonance over the left upper lobe.
    3. Hyperresonance over the left lower lobe.
    4. Dullness above the left 10th intercostal space.
    2. Resonance over the left upper lobe is a normal sound over the lung.

    • pp. 1533
    • Chp. 30 #4
  41. Nurse Betty is performing an assessment of the abdomen after Suzie complains of painful bowel movements and stomach cramps. In what order should the nurse assess Suzie.

    1. Feel, 2. Look, 3, Listen
    LOOK, LISTEN, FEEL
  42. When discussing Documentation and Reporting what does the acronym SOAP stand for?
    • S-Subject Data
    • O-Objective Data
    • A-Assess
    • P-Plan
  43. Mr. Smith broke his hip two days ago. His pain scale is 8/10 and it is 9:55 A.M.. How would you document this using P.I.E.

    P-Problem I-Intervention E-Evaluation

    P-Mr. Smith is in pain. Where is the pain? Is it radiating? What releives his pain...e.g.

    ----Pain in left hip radiating to lower back. 8/10


    I: Intervention- Give Mr. Smith meds per MAR

    E: Evaluation- What happened afterwards?

    -----Pt complained of pain in Rt. Hip 8/10. 10:05 Demerol given IM in Left Vastus Lateralis for Rt Hip per MAR. 10:45 pt states he feels better and his pain is only a 3 now.

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