Health Assessment Final

what are examples of data found in the review of systems?

• pt. reports or symptoms within each body system

• chief complaints

what type of date is a review of systems?

SUBJECTIVE

why is the review of systems subjective data?

the pt. self reports of symptoms or issues they feel and how they feel

what are some of the information the nurse obtains by assessing present health status?

• medications

• allergies

• current health condition

• OLDCARTS of current chief complaint

subjective vs objective:

breast mass or lump

objective; nurse can use palpation to observe presence

subjective vs objective:

fear of coping

subjective; this is something that the pt. will report

subjective vs objective:

chest pain

subjective; pain is subjective and unique to each individual

non-modifiable risk factors for breast cancer

• age

• gender

• ethnicity

• hormonal function

• family history

modifiable risk factors for breast cancer

• nutrition (more fiber intake, less transfats)

• physical activity (at least 30 mins/day)

• alcohol (reduce consumption)

• smoking (cessation)

  • hormone replacement therapy

true or false:

men can have breast cancer

true

true or false:

lifestyle changes reduce the risk of breast cancer

true

true or false:

screening does not improve outcomes

false

true or false:

breast cancer is more prevalent in younder women aged 25-35

false

fill in the blank:

information about a person’s ___ can be obtained when the nurse assesses their dress, affect, hygiene, gait, and speech

mental, emotional, and behavioral status

which two assessments help to measure tissue perfusion?

• heart rate (determines effective pumping to tissues)

• pulse oximetry (determines if blood being pumped has enough oxygen)

the pt. has an irregular radial pulse on assessment, what is the priority nursing action

auscultate and record pts. apical pulse for one full minute

which vitamin and mineral support bone health and reduces the risk of osteoporosis?

• vitamin D

• calcium

fill in the blank:

S1 signifies the closure of the __ and __ valves

mitral and tricuspid (AV)

fill in the blank:

S2 signifies the closure of the __ and __ valves

aortic and pulmonic (SL)

where is S1 heard the loudest?

apex of heart (bottom)

where is S2 heard the loudest?

base of hear (top)

where in the cardiac cycle is S3 heard?

after S2

where in the cardiac cycle is S4 heard?

right after S1, between S1 and S2

modifiable cardiac risk factors

• smoking

• high cholesterol/hyperlipidemia

• high blood pressure

• high fat diet

• sedentary lifestyle

non-modifiable cardiac risk factors

• age

• ethnicity

• gender

the pt. complains of chest pain. what is the nurse’s priority intervention?

a. auscultate apical pulse for 1 full minute

b. administer nitroglycerin tablet sublingual

c. obtain ECG

d. obtain ABG (arterial blood gas)

c. obtain ECG

what is the normal breath sound heard in the lungs and thorax?

vesicular breath sounds

describe:

wheezing

high pitched whistling

describe:

crackles

rattling

describe:

rhonchi

snoring

which adventitious breath sound is most likely heard in a patient that is experiencing an asthma attack?

wheezing

signs of dehydration

• poor skin turgor/skin tenting

• dry mucus membranes

• flattened veins

• sunken eyes

• dry axillary area

• hypotension

• tachycardia

identify:

clubbing; associated with oxygen deficiency (COPD< heart failure)

identify:

jaundice; associated with liver disease

identify:

cyanosis; associated with hypoxia or lack of oxygen

identify:

erythema; unblanchable redness on skin cause by infection, allergy, friction, pressure, trauma, etc

*stage 1 pressure injury can present as erythema

identify:

ecchymosis/bruising; bleeding or blood under the skin caused by trauma to the area

identify:

purpura/senile purpura; associated with increased vessel fragility due to connective tissue damage or atrophy in the dermis caused by chronic sun exposure, aging, and drugs

identify:

pallor; associated with anemia

stage the following pressure ulcer:

stage 2

stage the following pressure ulcer:

stage 4

stage the following pressure ulcer:

stage 3

stage the following pressure ulcer:

stage 1

which quadrant would a nurse assess the following organ?:

liver

right upper quadrant

which quadrant would a nurse assess the following organ?:

appendix

right lower quadrant

which quadrant would a nurse assess the following organ?:

spleen

left upper quadrant

which quadrant would a nurse assess the following organ?:

full bladder

right and left lower quadrants

identify the appropriate finding with the following tympanic membrane:

perforated tympanic membrane

identify the appropriate finding with the following tympanic membrane:

fluid accumulation

identify the appropriate finding with the following tympanic membrane:

normal tympanic membrane

identify the appropriate finding with the following tympanic membrane:

infected tympanic membrane

identify the appropriate finding with the following tympanic membrane:

trauma

what does the following picture signify?

jugular vein distention possibly caused by fluid volume excess, hypervolemia, or heart failure

to appropriately assess JVD, what should the angle of the pt. bed be?

45 degrees