NURS 1300 > Exam 1 > Flashcards

Exam 1 Flashcards

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1
Q

What are the Four (4) SKILLS performed for ASSESSMENT TECHNIQUES?

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
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2
Q

True or False: Palpitation always comes first during assessment techniques.

A

FALSE, INSPECTION always comes first.

  1. First individual as a whole is inspected
  2. Then each body system is inspected
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3
Q

What THREE (3) things does INSPECTION require?

A
  1. Good lighting
  2. Adequate exposure
  3. Occasional use of instruments
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4
Q

What NINE (9) things does PALPATION assess?

A
  1. Texture
  2. Temperature
  3. Moisture
  4. Organ location/size
  5. Swelling, vibration or pulsation
  6. Rigidity/spasticity
  7. Crepitation
  8. Lumps/masses
  9. Tenderness/pain
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5
Q

What are the FIVE (5) uses of PERCUSSION?

A
  1. Organ mapping
  2. Signaling density
  3. Detecting superficial abnormal mass
  4. Eliciting pain where inflamed
  5. Eliciting deep tendon reflex
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6
Q

What are the TWO (2) METHODS of PERCUSSION?

A
  1. Direct

2. Indirect

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7
Q

This ASSESSMENT TECHNIQUE is the close, careful SCRUTINY of individual and each body system.

A

Inspection

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8
Q

This ASSESSMENT TECHNIQUE applies the SENSE of touch to assess.

A

Palpation

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9
Q

This ASSESSMENT TECHNIQUE requires TAPPING a person’s SKIN with short, sharp strokes to assess underlying structures.

A

Percussion

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10
Q

This ASSESSMENT TECHNIQUE requires LISTENING to sounds produced by the body.

A

Auscultation

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11
Q

This METHOD of PERCUSSION is sometimes called IMMEDIATE, because the striking hand CONTACTS the body wall.

A

Direct

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12
Q

This METHOD of PERCUSSION is sometimes called MEDIATE because BOTH HANDS are used, where the striking hand CONTACTS STATIONARY HAND.

A

Indirect

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13
Q

True or False: most body sounds are very soft and must be channeled through a stethoscope.

A

TRUE

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14
Q

True or False: stethoscopes work by magnifying body sounds which make it easier to hear them.

A

FALSE, stethoscopes do not magnify body sounds but they do BLOCK OUT extraneous sounds.

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15
Q

This is a CRUNCHING SOUND that can be hear from the body.

A

Crepetation

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16
Q

This PART of the STETHOSCOPE uses LIGHT PRESSURE to auscultate LOW FREQUENCY sounds.

A

Bell

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17
Q

This PART of the STETHOSCOPE uses FIRM PRESSURE to auscultate HIGH FREQUENCY SOUNDS.

A

Diaphragm

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18
Q

What are the FIVE (5) major VITAL SIGNS?

A
  1. Temperature
  2. Pulse
  3. Respiration
  4. Blood pressure
  5. Pain
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19
Q

What is the RANGE for NORMAL body TEMPERATURE?

A
  1. 8- 37.3 degrees Celsius

96. 4- 99.1 degrees Fahrenheit

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20
Q

True or False: rectal temperatures are typically higher compared other routes.

A

TRUE, RECTAL temperatures are usually 0.4- 0.5 degrees Celsius (0.7- 1 degrees Fahrenheit) HIGHER.

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21
Q

What FOUR (4) things INFLUENCE normal TEMPERATURE?

A
  1. Exercise
  2. Age
  3. Diurnal Cycle (time of day)
  4. Menstruation
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22
Q

What are the FIVE (5) ROUTES for TEMPERATURE recording?

A
  1. Oral
  2. Axillary
  3. Rectal
  4. Tympanic Membrane
  5. Temporal Artery
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23
Q

Term used for the AMOUNT of BLOOD each heart beat pumps into the AORTA.

A

Stroke Volume

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24
Q

What is the average STROKE VOLUME for ADULTS?

A

70 ml

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25
What FOUR (4) things does the GENERAL SURVEY assess?
1. Physical Appearance 2. Body Structure 3. Mobility 4. Behavior
26
What SIX (6) things are assessed in regards to PHYSICAL APPEARANCE?
1. Age 2. Sex 3. Level of Consciousness 4. Skin 5. Facial Symmetry 6. Signs of Acute Distress
27
What SEVEN (7) things are assessed in regards to BODY STRUCTURE.
1. Stature 2. Nutrition 3. Symmetry 4. Posture 5. Position (comfortable) 6. Body Build 7. Physical Deformities
28
What THREE (3) things are assessed in regards to MOBILITY?
1. Gait 2. Range of Motion 3. No Involuntary Movement
29
What FIVE (5) things are assessed in regards to BEHAVIOR?
1. Facial Expression 2. Mood/Affect 3. Speech 4. Dress 5. Hygiene
30
This is the STRENGTH of the heart's STROKE VOLUME.
Force
31
What are the scores of the THREE POINT SCALE for PULSE?
3+ full, bounding 2+ normal 1+ weak and thready 0 Absent
32
What are THREE (3) examples which could be the CAUSE of a FULL BOUNDING PULSE?
1. Anxiety 2. Exercise 3. Abnormal Conditions
33
What FOUR (4) things indicate NORMAL RESPIRATION?
1. Relaxed 2. Regular 3. Automatic 4. Silent
34
This is the FORCE of BLOOD PUSHING against the side of its CONTAINER.
Blood Pressure
35
This is the MAXIMUM PRESSURE felt on artery during LEFT VENTRICULAR CONTRACTION.
Systolic Pressure
36
This is the ELASTIC RECOIL or RESTING PRESSURE that blood exerts constantly between each contraction.
Diastolic Pressure
37
This is the DIFFERENCE between SYSTOLIC and DIASTOLIC pressure.
Pulse Pressure
38
True or False: pulse pressure reflects stroke volume.
TRUE
39
This is the PRESSURE FORCING into TISSUES and averaged over cardiac cycle.
Mean Arterial Pressure (MAP)
40
What is the RATIO of PULSE RATE?
4:1
41
What is the AVERAGE BLOOD Pressure in YOUNG ADULTS?
120/80
42
What SEVEN (7) factors might affect BLOOD PRESSURE?
1. Age 2. Gender 3. Race 4. Diurnal Rhythm 5. Weight 6. Emotions 7. Stress
43
What FIVE (5) factors DETERMINE LEVEL of BLOOD PRESSURE?
1. Cardiac Output 2. Peripheral Vascular Resistance 3. Volume of Circulating Blood 4. Viscosity 5. Elasticity of Vessel Walls
44
When measuring an ORTHOSTATIC BLOOD PRESSURE the patient's POSITION is changed from ___________ to ___________.
Supine to Standing
45
When an ORTHOSTATIC blood pressure is measured, a slight DECREASE in _____________ may occur.
Systolic pressure
46
True or False: the decrease in systolic pressure seen when an orthostatic pressure is measured is about 17 mmhg.
FALSE, the slight decrease in systolic pressure seen when an orthostatic pressure is measured is LESS THAN 10.
47
True or False: record blood pressure by using odd numbers.
FALSE, record blood pressure by using EVEN NUMBERS
48
What SIX (6) things should be RECORDED along with taking ORTHOSTATIC VITALS?
1. Position of patient 2. Arm used 3. Size of the BP Cuff 4. Rate of Pulse 5. Rhythm of Pulse 6. Regularity of Pulse
49
The WIDTH of the rubber bladder on an ANEROID SPHYGMOMANOMETER should equal ___% of the circumference of the person's arm.
40%
50
The LENGTH of the rubber bladder on an ANEROID SPHYGMOMANOMETER should equal ___% of the circumference of the person's arm.
80%
51
What THREE (3) things may be assessed during a GENERAL SURVEY of an AGING ADULT?
1. Physical appearance 2. Posture 3. Gait
52
This is ILL CURVATURE of the SPINE that may be seen in older adults.
Kyphosis
53
In regards to AGING ADULTS, weight ____________ during 80's and 90's.
Decreases
54
During 80's and 90's subcutaneous FAT is LOST from ______________ and ______________.
Face and Periphery **especially forearms**
55
During 80's and 90's subcutaneous FAT is DEPOSITED to ______________ and ______________.
Abdomen and Hips
56
True or False: long bones do not shorten with age.
TRUE, long bones DO NOT SHORTEN with age
57
CHANGES in AGING PERSON'S body TEMPERATURE regulatory mechanism leave them LESS LIKELY to have _________.
Fever
58
CHANGES in AGING PERSON'S body TEMPERATURE regulatory mechanism leave them at GREATER RISK for _________.
Hypothermia
59
True or False: temperature is a reliable index of an older person's true state of health.
FALSE, temperature is LESS RELIABLE index of health for older people. **sweat gland activity is diminished**
60
How might the RADIAL ARTERY feel in an OLDER ADULT?
1. Stiff 2. Rigid 3. Tortuous **does NOT imply disease**
61
True or False: a pulse is usually harder to find on an older adult.
FALSE, pulse is actually EASIER to palpate in aging adults. **rigid arterial wall needs faster upstroke**
62
In regards to RESPIRATION, AGING ADULTS experience DECREASED ____________ and _____________.
1. Vital capacity | 2. Inspiratory Reserve Volume
63
True or False: the aorta and major arteries tend to harden with age.
TRUE
64
Because the AORTA is STIFFER in OLDER ADULTS, SYSTOLIC PRESSURE _____________.
Increases **leads to WIDENED PULSE PRESSURE**
65
What makes distinguishing NORMAL BP in AGED ADULTS from HYPERTENSION so difficult?
Systolic and Diastolic BP increase
66
True or False: a pulse oximeter can be placed on the earlobe.
TRUE
67
An SpO2 level in a HEALTHY PERSON is usually ____% to ____%.
97% to 98%
68
What are the THREE (3) INTERNAL FACTORS of COMMUNICATION.
1. Liking people 2. Empathy 3. Ability to listen
69
What are the SIX (6) EXTERNAL FACTORS of COMMUNICATION?
1. Privacy 2. Refuse Interruptions 3. Physical Environment 4. Dress 5. Note taking 6. Video/Tape recording
70
What are the THREE (3) PHASES of an INTERVIEW?
1. Introduction 2. Working 3. Termination
71
When are OPEN ENDED QUESTIONS used during the interview process?
1. Begin the interview 2. Introduce new set of questions 3. Patient introduces new topic
72
When are CLOSED ENDED QUESTIONS used during the interview process?
1. Fill in details a person may have left out 2. When you need many specific facts 3. To move along
73
What EIGHT (8) topics are discussed when obtaining a HEALTH HISTORY?
1. Biographical data 2. Source of History 3. Reason for Seeking care 4. Present health/history of illness 5. Past Health 6. Family History 7. Review of Systems 8. Functional Assessment (ADLs)
74
What NINE (9) things are obtained when gathering BIOGRAPHICAL DATA?
1. Name 2. Address/Phone 3. Age & DOB 4. Birthplace 5. Sex 6. Marital Status 7. Race 8. Ethnic Origin 9. Occupation
75
This is a SUBJECTIVE SENSATION a person feels from a disorder.
Symptom
76
This is an OBJECTIVE ABNORMALITY that can be detected on physical examination or laboratory reports.
Sign
77
What EIGHT (8) things are gathered when obtaining PRESENT HEALTH or HISTORY of present ILLNESS?
1. Location 2. Character/Quality 3. Quantity/Severity 4. Timing 5. Setting 6. Aggravating/Relieving Factors 7. Associated Factors 8. Patient's Perception
78
What TEN (10) things are gathered for PAST health HISTORY?
1. Childhood Illnesses 2. Accidents/Injuries 3. Serious/Chronic Illnesses 4. Hospitalization S 5. Operations 6. Obstetric History 7. Immunizations 8. Last Exam 9. Allergies 10. Medications
79
True or False: pain is always subjective.
TRUE
NURS 1300
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