Exam 3 Health Assessment Fortis College

What is lethargy?

Limited spontaneous movement, sluggish speech, drowsy, falling asleep quickly

What is obtunded?

Confused, Sleeps most of the time, difficult to wake. Speech mumbled and difficult to wake.

What is delirium?

Acute confusional change or loss of consciousness and perceptual disturbance

What is stupor?

Partial or almost complete unconsciousness. Spontaneous consciousness, has appropriate motor response.

What clinical symptoms does the nurse assess in a patient with posttraumatic stress syndrome?

Relives trauma, same feelings arise. Avoidance of triggers, hypervigilance, sleep problems, difficulty concentrating, leading to feelings of perm damage. High Anxiety!

What are illusions?

misperceptions of real external stimuli

What are delusions?

fixed false beliefs

What is hypochondriasis?

Morbid worrying about own health. Feels sick with no actual reason.

What are hallucinations?

false sensory experiences, such as seeing something in the absence of an external visual stimulus

How does the nurse assess for Dysarthria?

Assess if the patient is able to form words and articulation is clear and understandable

How does a nurse assess for Dysphonia?

Judge the quality of speech by noting if the person makes laryngeal sounds effortlessly and shares conversation appropriately.

How does the nurse assess for Aphasia?

Word choice is effortless and appropriate for educational level. The person completes sentences and pauses to think.

How is orientation usually lost?

First to time, then to place and rarely to person.

How does recent memory defecate occur?

delirium, dementia, amnestic syndrome, or Korsakoff syndrome in alcoholics.

What are the four main headings in mental status assessment?

ABCT- Appearance, Behavior, Cognition and Thought process.

What is mental status?

a person's emotional and cognitive functioning

What is a mental disorder?

a significant impairment in psychological functioning

What are the two reasons most people seek medical care?

Anxiety and depression

What is the PHQ-2

A screening tool for depression

What is the Mini-Mental State Examination?

It is an examination done to assess a client's cognitive status by evaluating the following:

a. Orientation to time and place

b. Attention span and ability to calculate by counting backward by seven

c. Registration and recalling of objects

d. Language: including naming objects, following commands, and ability to write

If a person is alert

They are awake and readily aroused

If a person is in a coma

They are completely unconscious

What is Broca's aphasia?

"broken speech", trouble speaking, halting/jarring speech but you can understand what people are saying"

What is global aphasia?

Both receptive and expressive

What is Wernicke's aphasia?

"fluent aphasia", nothing the person says makes logical sense and you have trouble understanding"

What is systole?

Contraction of the heart. Emptying of the blood into the ventricles. as pressure within the ventricles rises, the mitral and tricuspid valves snap shut. This produces the first heart sound, S1.

How does blood flow through the heart?

Inferior and superior vena cava (1) dump blood into the right atrium (2)

Right ventricle (3)

2 pulmonary arteries (4) that lead to the lungs (5) where blood becomes oxygenated

Pulmonary veins (6) bring blood from the lungs back to the left atrium (7)

Left ventricle (8) is large and muscular to pump blood into the aorta (9) and to the rest of the body (10)

Eventually blood will be pumped back to each vena cava (1)

What is mitral stenosis?

narrowing of the mitral valve. due to calcification.

What heart sound do you hear with mitral stenosis?

S1 heart sound is accentuated, opening snap after the S2 heard over wide area of the pericardium followed by a murmur.

What is a murmur?

gentle, blowing, swooshing sound that can be heard on the chest wall. Low pitched diastolic rumble between S1 and S2 heart sounds.

When does the S1 heart sound occur?

At the beginning of systole (end of diastole). LUB

When does the S2 heart sound occur?

At the beginning of Diastole (end of systole). DUB

When does the S3 heart sound occur?

Immediately after S2

When does the S4 heart sound occur?

before S1 at the end of diastole

What activity is associated with a P-Wave?

Repolarization of the Atria

What is the QRS complex?

depolarization of the ventricles

What is the T wave?

repolarization of ventricles

What is a bruit?

turbulent blood flow

How does a bruit sound?

Blowing or Swishing

Where is a spot you can hear a Bruit?

The Carotid Artery

A PT has a possible stroke what does the term FAST stand for?

F- Face

A- Arm Weakness

S- Speech Difficulty

T- Time to call 911

What is the correct technique to assess the vessels in the neck in an older person?

Keep the neck in neutral position use the bell of the stethoscope.

What is the range for a normal heart rate in a healthy young adult?

60-100 BPM

Where does the nurse place the stethoscope to listen to the carotids?

angle of the jaw, at the base of the neck and midclavicular at the middle of the neck

How do you grade a pulse?

4+= Bounding 3+=Increased 2+= Normal 1+=weak 0= absent

What does the spleen do?

filters blood, stores RBC, produces antibodies

What does a tangential light do?

Uses light and shadows to point out imperfections

What is dyspnea?

shortness of breath

What is orthopnea?

difficulty breathing while lying down

What is cyanosis?

blue discoloration of the skin

What is pallor?

Pale skin

What is nocturia?

excessive urination at night

What does APE MAN stand for?

aortic, pulmonic, erb's point, tricuspid, mitral

Where do you find the apical impulse?

4-intercostal space @ or inside the midclavicular line

What is peripheral arterial disease?

disease of blood vessels supplying the arms and legs

Where are the major pulses nurses feel for?

Temporal, Cortaid, Brachial, Radial, Tibial, Aortic, Femoral, Popliteal, Dorsalis Pedis, Apical, Tibias Posterior.

The Physician tells you that the patient has an arterial obstruction in the foot what finding would you expect?

Absent pulse

The Patient has arterial insufficiency of the lower extremities. Which assessment finding would confirm that condition?

Using a doppler

What order does the heart layers go in from outside to inside?

Pericardium, Myocardium, Endocardium

When do the AV valves open?

during diastole, or the hearts filling faze.

What are the AV valves?

tricuspid and mitral

What is considered the pace maker of the heart?

SA node

What order does electrical impulse come in from the heart?

SA Node, AV Node, Bundle of His, Bundle Branches

How do you calculate cardiac output

CO=HRxSV

What is preload?

venous return that builds during diastole

What is afterload?

peripheral resistance against which the left ventricle must pump

What are the risk factors peptic ulcer disease?

frequent use of NSAIDs, alcohol, smoking, h. pylori infection

What is a pulse deficit?

the difference between the apical pulse and the radial pulse

How do you calculate pulse deficit?

apical pulse minus radial pulse

What quadrant is the liver located in?

RUQ

What quadrant is the stomach, spleen and pancreas located in?

LUQ

What quadrant is the sigmoid colon located in?

LLQ

The patient has hyperactive bowl sounds (Borborygmus). What are the common causes of this activity?

Increased motility, Early mechanical bowl obstruction, Gastroenteritis, Brisk Diarrhea, laxative use, subsiding paralytic ulcers.

What are the symptoms of appendicitis? which quadrants are involved?

starts with dull diffused preumbilicial pain shifts to sever sharp persistent pain. Pain an tendinous a RLQ (McBurney Point). Aggravated by movement and coughing. PT may exhibit deep breathing, anorexia, nausea, vomiting and fever.

What test can the nurse use to test for appendicitis?

Iliopsoa muscle test- Person in supine position, lift the right leg straight up, flexing at the hib; then push down over the lower part of the right thigh as the person as the person tries to hold up the left leg. test is negative is the person feels no pain.

Rebound test (Blumberg sign)- Push down slowly and deeply and lift up quickly. Negative if there is no pain.

The nurse need to assess the PT spleen what is the first step in this assessment?

Reach Left hand over the abdomen and behind the left side at the 11th and 12th rib. Lift hand up for spleen

What are the symptoms of kidney stones?

Dysuria (pain when urinating)

Haematuria (blood in urine)

Reduced urine flow

Low back pain

Renal colic (pain)

Strangury (pain inhibiting micturition)

Fever

The nurse notes tender sigmoid colon in the PT being assessed. What is the significance of this finding?

Normal

What are the correct steps in abdominal assessment?

1) Void first

2)Inspect

3)Auscultate

4)Percuss

5) Palpate

What is the first step in assessing the liver?

You always palpate LAST!!

Why is assessment of the liver and liver functions so important in older adults with regards to medication?

Drug Metabolism is impaired bc of blood flow through the liver and the liver size is decreased. Prolonged liver metabolism caused increased side effects.

What is the typical color and shape of striae? Why do pregnant women often develop these?

silvery, white, linear and jagged. occurs due to elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching.

PT falls sustaining possible injuries. what assessment technique does the nurse do first?

Inspection for dilation

How is Phalen's Test done? what is normal?

Hold both hands back to back while flexing muscles in arms. normal if no symptoms.

A Pt walks up the stair and hears "crunching" sounds? What word describes what the patient is experiencing?

Crepitation

What is grade 5 muscle testing result

Full ROM against gravity, full resistance

What is grade 4 muscle testing result

Full ROM against gravity, some resistance

What is grade 3 muscle testing result

Full ROM w/ Gravity

What is grade 2 muscle testing result

Full ROM w/ gravity is eliminated

What is grade 1 muscle testing result

short contractions

what is grade 0 muscle testing result

no contractions

A PT tells the nurse she has osteoarthritis. what question(s) will the nurse ask the PT about joints?

Any stiffness or swelling? Heat, tenderness to joints? Limitation of movement.

What leads to accelerated bone loss in older women?

Menopause b/c of lack of estrogen. BMI underweight.

Moving arms to the side and slightly inward would be call what kind of ROM?

Adduction

Moving the hips and knees away from the body is call what kind of ROM?

Abduction

Standing up is what kind of ROM?

Extension

Walking on your heels is what kind of ROM?

Dorsal Flexion

The spine has how many connecting bones?

33

There are how many cervical bones in the body?

7

There are how many lumbar bones in the body?

5