HESI NSG121/ NSG 121 (Latest 2024/ 2025 Update) Health Assessment | Review with Questions and Verified Answers| 100% Correct| Grade A- Herzing
HESI NSG121/ NSG 121 (Latest 2024/ 2025
Update) Health Assessment | Review with
Questions and Verified Answers| 100%
Correct| Grade A- Herzing
Q: Nutritional Assessment
Answer:
Risk factors to review in a nutritional assessment include medical history, abnormal weight
history, appetite or taste changes, gastrointestinal symptoms, food allergies or intolerances,
changes in eating or fluid patterns, poor food habits, inability to cook, social isolation, multiple
medications, inappropriate supplements or lack of supplements, and alcohol or drug use.
Consider a board range of influences on patient’s food choices
Q: Mental Orientation
Answer:
Person, Place, Time, Situation
Q: CAGE
Answer:
CAGE is a self report questionnaire used as an assessment tool for drugs and alcohol. Yes to two
or more of the questions indicate a potential problem
Cutdown,Annoyed,Guilty,Eye Opener
Q: Abstract Thinking
Answer:
Assessment of thought processes:
Patient’s thoughts are easy to follow, logical, coherent, relevant, goal directed, consistent, and
abstract
Abstract Thinking: Ability to understand concepts that are real
Q: Referred Pain Appendicitis
Answer:
Referred pain originates from a specific site, but the person experiencing it feels the pain at
another site along the innervating spinal nerve
It will “refer” pain often to the mid upper abdomen, the epigastrum. Because the appendix is a
piece of intestine, it follows a similar referral pattern.
Q: Nail Ridges in Geriatric Patients
Answer:
Longitudinal ridging is common in aging patients
Q: Skin Turger Assessment
Answer:
Assess skin turgor. Gently grasp a fold of the patient’s skin between your fingers and pull up,
then release. Below clavicle
Tenting indicates dehydration, poor skin turgor is also associated with aging
Q: Clubbing Oxygen Saturation
Answer:
Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail
to the finger is more than 160º
Emphysema or congestive heart failure
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Open Ended Question When obtaining a nursing history, use the open-ended question technique to allow the patient a wide range of possible responses.
Interpreter Person who can translate between languages.For patients who do not speak English, use an interpreter whenever possible
Interrupting Client Do not interrupt clients, in health care settings, it is better to listen than to talk and to ask good questions rather than have all of the right answers.
BMI Risk Assessment An assessment of risk factors includes questions about past medical and surgical histories, medication and supplement use, family history, food and fluid intake patterns, and the patient’s psychosocial profile
Low BMI Below 18.5
Normal BMI 18.5-24.9
Nutritional Assessment Risk factors to review in a nutritional assessment include medical history, abnormal weight history, appetite or taste changes, gastrointestinal symptoms, food allergies or intolerances, changes in eating or fluid patterns, poor food habits, inability to cook, social isolation, multiple medications, inappropriate supplements or lack of supplements, and alcohol or drug use.Consider a board range of influences on patient’s food choices
Mental Orientation Person, Place, Time, Situation
CAGE CAGE is a self report questionnaire used as an assessment tool for drugs and alcohol. Yes to two or more of the questions indicate a potential problemCutdown,Annoyed,Guilty,Eye Opener
Abstract Thinking Assessment of thought processes:Patient’s thoughts are easy to follow, logical, coherent, relevant, goal directed, consistent, and abstractAbstract Thinking: Ability to understand concepts that are real
Referred Pain Appendicitis “Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerveIt will “”refer”” pain often to the mid upper abdomen, the epigastrum. Because the appendix is a piece of intestine, it follows a similar referral pattern.”
Nail Ridges in Geriatric Patients Longitudinal ridging is common in aging patients
Skin Turger Assessment Assess skin turgor. Gently grasp a fold of the patient’s skin between your fingers and pull up, then release. Below clavicleTenting indicates dehydration, poor skin turgor is also associated with aging
Clubbing Oxygen Saturation Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160ºEmphysema or congestive heart failure
Pallor Dark Skin Normal skin color is pink, noting the usual undertones present with even dark skin. The tongue, lips, nail beds, and buccal mucosa are less pigmented areas and may be the best indicators of pallor or cyanosis. Patients with darker skin may normally have hypopigmented skin on the palms and soles
Lesion Assessment & Primary vs. Secondary Lesion Primary Lesion: arise from previously normal skinSecondary Lesion: follow primary lesions (scare tissue)If observed, note the shape and measure the length, width, and depth with a ruler. If a wound is deep or tunneled, insert a cotton applicator to measure depth.
Goiter Assessment Palpation of Thyroid, Unilateral Bulging
Fall Assessment After a Fall Falls or sudden jerking of the head and neck (whiplash) are particularly likely to result in dislocation of the cervical vertebrae. Fractures may also occur with headfirst falls. Any history of falls or sudden jerks of the neck requires careful investigation.
Snellen Test Tests for far vision & visual acuity.Snellen test, measure and place a mark or piece of masking tape on the floor 6 m (about 20 ft) from the chart
Tinnitus Tinnitus: buzzing or ringing in one or both ears that does not correspond with external sound
Conductive Hearing Loss BC that is longer than or the same as AC is evidence of conductive hearing loss. Conductive hearing loss on one side may indicate external or middle ear disease. Patients with conductive hearing loss should have an assessment of the auricle and external auditory canal to look for blockage
Assessment of Mouth/Tongue Holding a light in the nondominant hand and a tongue blade in the dominant one, gently separate areas to fully inspect the buccal mucosa, noting color and pigmentationSmall, isolated, white or yellow papules (Fordyce granules) may be noted on the cheeks, tongue, and lips. These sebaceous cysts or salivary tissues are insignificant
Newborn Temperature 97.7 F to 98.6 F (36.5 C to 37 C)
Newborn Flaring Nares Nasal flaring is a sign of respiratory distress
ADLs Mobility impairments affecting activities of daily living (ADLs) and instrumental activities of daily living (IADLs)
Carotene Rich Foods The richest sources of beta-carotene are yellow, orange, and green leafy fruits and vegetables (such as carrots, spinach, lettuce, tomatoes, sweet potatoes, broccoli, cantaloupe, and winter squash). In general, the more intense the color of the fruit or vegetable, the more beta-carotene it has
APGAR 1 min & 5 min7-10 indicates vigorous newborn adapting wellIf the 5-minute score is less than 7, continue to score every 5 minutes up to 20 minutes until the score is above 7, the newborn is intubated, or the newborn is transferred to the nursery.A score of 4-6 indicates the newborn is moderately depressed, and 0-3 indicates severe respiratory depression and requires observation and care in a NICU.
Pregnancy Weight Gain A simple rule of thumb for a woman of normal prepregnant weight is that she will gain about 10 lb by 20 weeks and about 1 lb/week for the remaining 20 weeks, for a total of 25-30 lb
Pregnancy Back Pain “Backache due to breast changesBackaches are common during the second and third trimesters, partly from lumbar lordosis of pregnancy and partly from poor back support when lifting or sleeping. Increased weight from the fetus and breast tissue, with the accompanying change in the center of gravity, places increased strain on the abdominal muscles. Teach the pregnant woman exercises to strengthen her abdominal muscles (pelvic tilts), and suggest a support band, which may provide some relief. Increased levels of relaxin loosen the cartilage between the pelvic bones, resulting in the characteristic “”waddling”” gait of the third trimester.”
Morning Sickness Help Drinking ginger in water or tea can help decrease nausea & vomiting
When does ovulation occur? On average 28-day menstrual cycle, ovulation occurs 14 days before the start of the next menstrual period.
Deep Tendon Reflexes Assessment Deep Tendon Reflexes. DTRs tested include biceps, triceps, brachioradialis, patellar, and AchillesThese reflexes are observed for symmetry when tested bilaterally and for briskness of reflex movement. DTRs are graded on a scale of 0-4, with 0 representing absent reflexes and 4 corresponding to significantly hyperactive responses.4+—Very brisk, hyperactive with clonus3+—Brisker than average2+—Average, normal1+—Diminished; low normal0—No response
Temperature Tactile Differentiation Temperature Sensation. Test temperature sense only if pain or touch sensation is abnormal. Use one prong of a tuning fork that has been warmed with the hands or use test tubes containing warm and cold water. Ask the patient to close the eyes. Touch the skin with warm or cold objects. Have the patient identify when he or she feels warm or cold.
Two Point Discrimination Two-Point Discrimination. This test is done only if other findings are abnormal. With the patient eyes open, demonstrate what the cotton swabs feel like. Then ask the patient to close the eyes. Hold the blunt end of two cotton swabs approximately 5 cm (2 in.) apart and move them together until the patient feels them as one point (the ends of an opened paperclip may also be used)
Romberg Sign In the Romberg test, ask the patient to stand with feet together and arms at sides. Note any swaying (stand close enough to prevent the patient from falling). Ask the patient to close the eyes during the Romberg test for additional assessment. Slight swaying may be normal because visual cues help humans to maintain balance
Stuporous Neurological Status Patient is unresponsive and can be aroused only briefly by vigorous, repeated stimulation.
Neurological Assessment LOC Spontaneous, Normal Voice, Loud Voice, Tactile, Noxious (pain)
Heberden’s Nodes Outgrowths that are boney and found on the hands are due to bone spur formationHeberden’s Node (most common): found on the distal interphalangeal joint (joint closest to the finger nail)
Shoulder ROM Degrees ROM is normal: forward flexion 180 degrees, hyperextension 50 degrees, abduction 180 degrees, adduction 50 degrees, internal rotation 90 degrees, and external rotation 90 degree
Muscle Strength Assessment 5/5 normal, complete ROM against gravity & full resistance4/5 good, complete ROM against gravity & moderate resistance3/5 fair, complete ROM against gravity2/5 complete ROM with join supported, cannot perform against gravity1/5 Trace, muscle contraction but no movement0/5 no visible muscle contraction
Ataxia Assessment Ataxia (irregular uncoordinated movements) or loss of balance may be due to cerebellar disorders, Parkinson disease, multiple sclerosis, strokes, brain tumors, inner ear problems, or medications.gait, stance, sitting, speech disturbance, finger chase, nose-finger, fast alternating hand movements, & heel shin
Normal Bowel Sounds There are 5-30 gurgles per minute or one sound every 5-15 seconds in the average adult. Sounds indicate bowel motility and peristalsis. Listen in each quadrant for a full minute. If no sounds are audible, listen for up to 5 minutes
Abdomen Auscultation for Bruit Bruits are swishing sounds that indicate turbulent blood flow resulting from constriction or dilation of a tortuous vessel. Bruits in the hepatic area indicate liver cancer or alcoholic hepatitis. Bruits over the aorta or renal arteries indicate partial obstruction of the aorta or renal artery.
Borborygmi Increased bowel sounds, called borborygmi, occur with diarrhea and early intestinal obstruction
Assessment for Anal Hemorrhoids Observe anus while patient bears down, then lubricate index finger and have patient take deep breath while you insert finger. Should feel full closure around finger. Can be external or internal.Hemorrhoids are usually caused by constant or excessive straining upon defecation
Testicular Self Examination Testicular Self ExaminationRight after hot shower or bath, examine each testicle one at a timeRoll testicle between your fingers making note of any lumps or swelling or changes
Abdmoninal Palpation for Elderly Dividing the abdomen into 4 quadrants assists with location of the underlying organs. The elderly are less likely to feel pain with abdominal conditions and do not always present with classic symptoms and laboratory findings. They are more likely to have vague diffuse pain and tend to have a less acute presentation.
Allen Test When indicated, perform the Allen test to assess the patency of the collateral circulation of the hands (Fig. 18.9). Ask the patient to make a fist. Occlude the radial and ulnar arteries of the same hand. Have the patient open the hand; release pressure on the ulnar artery. Do the same with the radial artery.
Palpation of Pulses & Scoring Palpate bilateral pulses at the same time and compare0: non palpable1+: weak & thready2+: normal & expected3+: full & increased4+: bounding
S1 & S2 Heart Sounds S2 louder at Aortic & PulmonicS1 louder at Tricuspid & MitralS1=S2 Erb’sS1 Lub correlates with carotid pulseS2 Dub correlates with beginning of diastole
JVD Assessment Jugular venous distention (JVD) is associated with heart failure, tricuspid regurgitation, and fluid volume overload. The neck veins appear full, and the level of pulsation may be have elevated JVP greater than 3 cm (about 1¼ in.) above the sternal angle
Lymphatics Assessment & Suggestions Edema in extremities is a primary symptom of lymphedemaSuggest patient avoid sitting or standing for long periods of time and wear compression socks to help decrease swelling
Assessment of PMI The point of maximal impulse (PMI) is a term used to describe the area where the apical pulsation can be seen or palpated. In most adults, this impulse can commonly be found at the intersection of the 5th ICS mitral area and the left MCL in the mitral area.
Auscultation Equipment Stethoscope on skin
Egophony Assessment “To assess for egophony, ask the patient to repeat “”e e e”” while you are auscultating the chest in the usual locations, comparing sides.In egophony, the “”e e e”” sounds like a loud “”a a a.”” This finding is often documented as “”Egophony: e ã a changes”” or positive egophonyEgophony is negative when the sound is muffled and difficult to hear.”
Vesicular Lung Sounds Vesicular breath sounds are soft, low-pitched, and found over fine airways near the site of air exchange (the lung periphery).Inspiration greater than expiration, Over most of lung fields
Pneumonia Auscultation Findings “Abnormal: The word “”ninety-nine”” is clear and louder over denser areas. It sounds as if the patient is speaking directly into the stethoscope. This is documented as positive bronchophony. Pneumonia is present 96%-99% of the time in patients with bronchophony, but patients with pneumonia seldom have itRhonchi: low pitched snoring or gurgling”
Respiratory Splinting Respiratory splinting is defined as reduced inspiratory effort as a result of sharp pain upon inspiration (severe pleuritic chest pain). This can result in atelectasis post-operatively
Which factor is most likely to contribute to the development of osteoarthritis? High body mass index.
What should the practical nurse (PN) do if an unusual and unexpected event occurs that involves a visitor or staff member? Fill out an incident report immediately.
The practical nurse (PN) is participating in a committee that is evaluating sentinel events across all nursing units. Which situation should the committee review as a sentinel event? Hemolytic transfusion reactions involving major blood group incompatibilities.
The practical nurse (PN) is evaluating a client’s outcomes. Which statement indicates a client has achieved improved health? Laboratory results have returned to normal levels.
The client had an indwelling urinary catheter removed an hour ago and now reports a sensation of fullness, discomfort, and dribbling of urine when voiding. What is the first action the practical nurse (PN) should take? Perform a bladder scan 5 to 15 minutes after the client has voided.
Which questions would be relevant for a practical nurse (PN) to ask a client who suffers with chronic pain? Select all that apply -What makes it better or worse?-Can you show me where it hurts?-How would you describe the pain?-How has this pain affected your life?
What interventions can the practical nurse (PN) implement to help minimize the risk of falls in a client who has been identified as having a high fall risk? “-Perform hourly bedside rounds.-Use chair and bed alarms.-Educate client about fall prevention.-Place a “”fall risk”” sign on client’s door.”
What is the main purpose of performing range of motion (ROM) and passive range of motion (PROM) exercises? Prevention of contracture development.
What strategies should the practical nurse (PN) implement when assisting an older client with self-care deficits? -Give the client adequate time for completion of activities.-Instruct in the use of assistive devices such as a button hook and sock assist.-Modify activities of daily living to client’s abilities such as sitting to brush teeth.-Plan time schedule, daily activities, and staffing according to the client’s functional ability.
The practical nurse (PN) is teaching a pre-op client in preparation for care following surgery. Which methods should the PN teach about pulmonary toileting? -To use an incentive spirometer at least four times an hour.-To breathe deeply through the nose and exhale through the mouth.
he practical nurse (PN) is auscultating the lung fields of a client who has been diagnosed with emphysema. The PN notes high-pitched, whistling sounds throughout all lobes of the lung. Which term best describes this lung sound? Wheezing.
A client’s pulse oximeter is alarming and displaying 80% O2 saturation. The client is lying in bed with O2 running at 2 liters/min via nasal cannula. The client’s respiratory rate is 16 breaths per minute, mucous membranes are pink,and breathing is not labored. What should the practical nurse (PN) do next? Check that the placement of the pulse oximeter is correct.
The practical nurse (PN) has been transferred to a new nursing unit and wishes to begin building collaborative, interdisciplinary relationships. Which characteristics would contribute to effective teamwork? -Effective and consistent communication.-Trust and mutual respect.-Recognition and valuation.
The unlicensed assistive personnel (UAP) is assisting a client getting into the shower. The charge nurse answers a call from the fracture clinic to immediately send the UAP’s other assigned client to the clinic. Which action should the practical nurse (PN) take? Notify the delegating nurse of the current request from the fracture clinic
Which information should the practical nurse (PN) include in a report of a client being admitted to the nursing unit from the emergency department (ED)? -Admitting diagnosis.-Current code status.-Treatment done in ED.
A client is experiencing cancer-related fatigue. What should the practical nurse (PN) advise to help alleviate the symptoms? -Try to eat a well-balanced diet.-Participate in routine physical exercise.-Develop routine sleeping habits.
A mother asks for advice on how to talk to her children about death and dying after she learned that her husband has approximately six months to live. How should the practical nurse respond to the mother? -Ask the mother about her beliefs about death and dying.-Assess how the mother feels about the situation.-Inquire about her children’s previous experiences with death and dying.
A survivor of a horrific motor vehicle accident whose loved one was killed has not been able to go back to work and spends most of the day drinking alcohol and watching television for the past ten months. Which type of complicated grieving is being exhibited? Exaggerated grief.
The practical nurse (PN) is preparing to conduct a general mobility assessment with a client. When should the nurse begin the mobility assessment? While the client is lying in bed.
“Which questions are best for the practical nurse (PN) to ask to assess for “”disuse syndrome”” in clients diagnosed with neuromuscular diseases such as muscular dystrophy or multiple sclerosis?” -What is included in a typical day for you?-How much assistance do you need to move around?-On a scale 1-10, how would you rate overall pain level?
Which dosing routes are acceptable for the practical nurse (PN) to administer fentanyl to a client diagnosed with cancer who is suffering with chronic pain? -PCA pump.-Transdermal patch.-Transmucosal swab.-Slow intravenous push.
The practical nurse (PN) is assessing the femoral insertion site of a client who recently had a cardiac catheterization. The client reports discomfort at the site. According to the standing orders, which action should the PN implement? Administer acetaminophen/ codeine phosphate.
The practical nurse (PN) is providing client teaching about the use of a patient-controlled analgesia (PCA) pump. Which statement by the client indicates the need for more instruction about the PCA pump? If I am asleep, one of my visitors can push the button for me.
The practical nurse (PN) is providing nutrition counseling to a diverse group of clients. Which religions direct followers to avoid food items made with pork? -Islam.-Judaism.-Hinduism.
What should the practical nurse (PN) suspect when an older Asian client diagnosed with left lower lobe pneumonia has a pattern of uniform circular bruises on the left lower posterior thorax area? Use of complementary therapies.
A practical nurse (PN) travels to different parts of the country and changes nursing assignments every 4 months. What should the PN do to ensure that culturally competent nursing care is delivered? -Gather health disparities information about the region.-Review the occurrence and prevalence of illnesses for that region.-Become familiar with the different cultural practices of the region.
The practical nurse (PN) is administering beta-blocker eye drops for a client’s glaucoma. What is the most important step to prevent the client from experiencing syncope or a fall injury? Apply pressure to the nasolacrimal duct after administration.
When doing an assessment of sensory nerve function, which test should the practical nurse (PN) omit if the pain sensation is normal? Temperature.
While assessing an adult client, the practical nurse (PN) identifies generalized edema in the client’s arms, legs, and periorbital regions. Which dietary influence could have contributed to this generalized edema? A diet low in protein.
The practical nurse (PN) is calculating a client’s fluid balance for the past 24 hours. The client had a total of 895 mL of IV fluid; 150 mL antibiotic IV; 16 ounces of water; two 4 ounce containers of gelatin; and one cup of creamy potato soup. The client voided 480 mL, 300 mL and 500 mL; vomited 300 mL and 175 mL. How many mL of positive fluid balance should be entered in the client’s electronic medical record? (Enter numeric value only.) 250 mL
Which electrolyte has a direct effect on a client’s blood pressure? Sodium.
A client with fluid overload is being treated with fluid restriction of 1 liter/day and diuretics. Which actions by the practical nurse (PN) would best evaluate the outcomes of this treatment? -Obtaining a daily weight.-Calculating the intake and output.-Checking for orthostatic hypotension
The practical nurse (PN) is reviewing laboratory results in the client’s electronic medical record. Which lab value may indicate a state of malnutrition? Low level of albumin.
The practical nurse (PN) is caring for a client whose BMI is 35 kg/m 2 . Which conditions is the client at greatest risk of developing? -Hypertension.-Hyperlipidemia.-Atherosclerosis.
Which foods should the practical nurse (PN) instruct a client diagnosed with end-stage renal disease to avoid? -Bananas.-Dark-colored colas.-Red meats.
What can happen if cold therapy is left in place for more than 30 minutes for the treatment of inflammation? -Vasodilation-Worsening of the inflammation
The Practical Nurse (PN) is discussing smoking cessation with a male client. Base on the Health Belief Model (HBM) what are effective strategies for the PN to use to encourage the client to stop smoking? -Ask the client how likely it would be for him to develop lung cancer.-Encourage the client to list how a smoke cessation program would benefit him.-Assess whether the client considers lung cancer a serious health condition.
“Which rights of medication administration are ensure with “”bar coding technology”” which requires the practical nurse (PN) to scan the medication, client’s identification bracelet and nurse’s identification badge prior to administration medication?” -Right dose-Right time-Right client
The practical nurse (PN) is irrigating a client’s wound. Which factor could delay wound healing as a result of wound irrigation? -The use of povidone-iodine solution-Hydrogen peroxide poured into the wound-Direct force of irrigation solution on wound-Irrigation solution cooler than room temperature
A client has a swollen, bruised, sprained ankle and states that the current pain level has risen from a 3 to a 5 on a 10 point scale. Which analgesic medication would most likely be prescribed to relieve this pain? Ibuprofen.
Which practical nursing (PN) tasks would be appropriate for the PN to assign to the unlicensed assistive personnel (UAP)? -Assisting clients with morning ADLs to include showering and shaving.-Transporting a client with a fractured wrist to the cast clinic for cast placement.
Which characteristics should be included in goals the practical nurse (PN) reinforces with a client? -Realistic.-Measurable.-Patient-centered.-Time frame.
Four clients are requesting pain medication and it is within their prescribed dosing time. All clients achieved pain relief after their last dose. Now the clients have reported their pain on a 1 to 10 pain scale. Which should be the first client the practical nurse (PN) administers pain medication? After the last dose, pain was 1 out of 10; now pain is 6 out of 10.
The practical nurse (PN) is irrigating a client’s wound. Which factors could delay wound healing as a result of wound irrigation? -The use of povidone-iodine solution.-Hydrogen peroxide poured into wound.-Direct force of irrigation solution on wound bed.-Irrigation solutions cooler than room temperature.
The practical nurse (PN) is reviewing the change of shift report. Which client should the nurse assess first? A 76-year-old client transferred from the emergency department who requires femur pinning due to a recent fall.
Which factors are most likely to decrease a client’s perception of pain? -Internal sense of control.-The biological response to exercise.-Positive previous experience managing pain.
A client describes a poorly localized pain as a squeezing and pressure sensation. If the pain is caused by inflammation, what type of pain is it? Visceral.
The practical nurse (PN) is working with a client who has increased intracranial pressure. What is the best position for this client? High Fowler’s.
Which practical nursing (PN) actions are required when performing a transcutaneous electrical nerve stimulation (TENS) procedure with a client? -Instruct the client to adjust the intensity of TENS stimulation for pain relief.-Ensure and review there is a healthcare provider’s prescription for the TENS.-Remove any hair or lotions from the skin where the electrodes are to be placed.
The practical nurse (PN) is teaching an adult client how to change the dressing covering a surgical wound. Which adult learning approach will best support the client in learning a new skill? Assess the client’s life experiences.
The practical nurse (PN) is discussing smoking cessation with a male client. Based on the Health Belief Model (HBM), what are effective strategies for the PN to use to encourage the client to stop smoking? -Ask the client how likely it would be for him to develop lung cancer.-Encourage the client to list how a smoking cessation program would benefit him.-Assess whether the client considers lung cancer a serious health condition.
Which client behavior indicates to the practical nurse (PN) the client who is most likely proficient in health literacy? Client questions the healthcare provider about their prescribed plan of care.
The mother of a four year old client reports that the child has been drowsy, is not eating well, and has a cough. The practical nurse (PN) notes that the child’s vital signs are within normal limits. Which laboratory test would best indicate a developing systemic infection? CBC with differential.
The practical nurse (PN) wears gloves and a gown when bathing a client, changing the client’s bed linens, and placing the dirty bed linens in a biohazard labeled laundry bag that is kept inside the client’s room. Which type of isolation precaution is the PN implementing? Contact precautions.
The practical nurse (PN) is teaching a group of daycare workers about healthy food choices for children. The PN stresses that adequate intake of fruit, vegetables, and protein is important in preventing which conditions? -Retarded growth.-Behavioral problems.-Developmental delays.
What is the wound closure called that occurs when the healing is prolonged because the skin or wound edges cannot be approximated? Secondary intention.
Which practical nursing (PN) task provides the best opportunity to complete a skin assessment? Bathing of a client.
Which signs or symptoms from a practical nursing (PN) assessment suggest a client is experiencing a form of stress? -Diarrhea.-Headaches.-Palpitations.
“A client diagnosed with an incurable terminal disease states “”If I adjust my work schedule, eat better and exercise more, I will be able to reverse the disease process and become disease-free””. The practical nurse (PN) recognizes that this client is exhibiting which stage of grief as described by Kubler-Ross?” Denial.
What can the practical nurse (PN) do to help facilitate the client’s adherence to a plan of care? -Include the client in the planning process.-Set realistic goals that are acceptable to the client.-Offer teaching that supports the desired plan outcome.
The practical nurse (PN) is advising a client to change high risk health behaviors. Which factors should the PN consider when challenging a client’s core beliefs? -Personal choices are supported by core beliefs.-Conflicting information may cause great distress.-Individuals seldom question their core beliefs.
The practical nurse (PN) is instructing a client about administering medication upon returning home from the hospital. Which recommendations support the client’s adherence to the prescribed plan of care? -Try using a pill organizer or automated phone reminder system.-Keep an updated medication list to bring to healthcare appointments.-Schedule medication administration times at the same time as other daily activities.
What are the legal implications of federally initiated healthcare acts on practical nursing (PN) practice? -Ignorance of the health acts is not permissible.-Encourages nurses to keep up with current standards.-Guides and defines legal boundaries of nursing practice.
Which medical conditions are most likely to affect sexual functioning in men or women? -Depression.-Colon cancer.-Uncontrolled hypertension.
Along with appropriate hand hygiene and respiratory etiquette, what practical nursing (PN) actions should be done next to prevent spread of a communicable disease from an infected client? Assist with rapidly identifying the disease and immediately isolating.
The practical nurse (PN) calculates a client’s body mass index (BMI). The client’s height is 6 feet and 6 inches (198cm) and the BMI is 30. How should the nurse categorize this BMI? Obesity.
The practical nurse (PN) is planning to teach a client about a prescribed medication. Which factor is most important in assuring the client will safely self administer the medication? Health literacy.
The practical nurse (PN) is assisting a client who is discouraged about losing weight. What skill can the nurse teach this client to encourage confidence, empowerment and motivation? Positive self-talk.
What are the three primary elements of the Health Belief Model (HBM) that predict how motivated clients are to change their self-care health behaviors? -The severity of the client’s illness.-The perception of susceptibility to the illness.-The client’s willingness to change lifestyle choices.
As the practical nurse (PN) inflates the balloon of a client’s indwelling urinary catheter, the client reports pain and discomfort. What should the PN do next? Stop and deflate the balloon of the catheter.
Which practical nursing (PN) intervention is considered the best way to prevent constipation with a post-op client? Encourage the client to drink 2000-3000 ml of fluid daily.
The practical nurse (PN) is assessing a client who has reported 7 episodes of diarrhea in the past 24 hours. What questions would determine a possible causative factor of the diarrhea? -Have you been experiencing any stress or anxiety lately?-Does the diarrhea have a strong, unpleasant odor to it?-What type of food have you eaten within the last 36 hours?-What medications and supplements are you currently taking?
The client had an indwelling urinary catheter removed an hour ago and now reports a sensation of fullness, discomfort, and dribbling of urine when voiding. What is the first action the practical nurse (PN) should take? Perform a bladder scan 5 to 15 minutes after the client has voided.
The practical nurse (PN) is teaching a female client who has had frequent urinary tract infections. Which statement by the client indicates the need for additional teaching? “””I need to wipe my perineum from the back to front after using the toilet.”””
4 Assessment Techniques Inspection, Percussion, Palpation, Auscultation
Aphasic Impairment of language or the inability to communicate through speech or writing due to brain dysfunction
Cognitively Impaired Difficulty thinking with loss of short or long term memory
3 Phase of the interview Introductory, Working, Summarization
What happens in the introductory phase? Introduce yourself and explain your role, establish rapport and trust, explain your purpose or reason for the interview, state the approximate time frame for interview and ask if the patient is comfortable
What happens in the working phase? This is the longest phase. Collect info about patient by asking open and close ended questions. This is where the patient reports their history, be alert of nonverbal cues
What happens in the summarization phase? Clarify the patients reports, needs, feelings and concerns. Summarize the patients self report. Confirm that the goals were validated by both you and the patient.
Comprehensive Health History Looks at the whole patient and reviews all body systems
Focused or problem based health history Focuses specifically on acute problems or symptoms
Follow-up health history Occurs after a patient has been seen; it concentrates on new data since the last history.
Primary Source Is the patient
Secondary Source Family members, significant others or medical records of the patient
Pack Year History There are 20 in a pack. So divide how many a day over 20 and multiply by how many years that person has smoked (X/20 x years)
HITS a domestic violence screening tool
CAGE A substance abuse screening tool
Sexuality sexual preferences, desires, and practices
Gender How you identify yourself
Mini Mental Exam Tests for cognitive impairment
Nutrition The state of balance between nutrient intake and physiological requirements for growth and physical activity
complete blood count (CBC) comprehensive blood test that includes red blood cell count (RBC), white blood cell count (WBC), hemoglobin (Hgb), hematocrit (Hct), white blood cell differential, and platelet count
Diabetes Mellitus A metabolic disease producing high blood sugars; individuals have a tendency to gain weight or to be overweight
Cushing’s Syndrome A hormonal disorder caused by high levels of cortisol; individuals have a tendency to gain weight
Hyperthyroidism An overproduction of the thyroid hormones; basal metabolic rate increases causing weight loss
Hypothryoidism A decreased production of the thyroid hormones; basal metabolic rate decreases causing weight gain
BMI less than 18 Underweight
BMI between 18.5-24.9 Normal BMI
BMI greater than 25 Overweight
BMI 30-39 Obese
BMI 40 or higher Morbidly Obese
Normal findings for assessing the abdominal circumference Males: less than or equal to 102 cm (40 in)Females: less than equal to 88 cm (35in)
Abnormal findings for assessing abdominal circumference Males: greater than 102 cm (40in)Females: greater than 88 cm (35in)
Mid-upper arm circumference normal findings Male: less than or equal to 23 cmFemale: less than or equal to 22cm
Mid-upper arm circumference abnormal findings Male: less than 23Female: less than 22Indicates that patient may be malnourished
Direct Inspection carefully observing and inspecting a specific area or the whole individual
Indirect Inspection Using specific equipment to improve your visualization of an area
Inspection requires which senses? Seeing, Hearing, Smelling
Inspection to look and asses the physical aspects of the body, posture, appearance and behaviors carefully
Palpation To touch and feel for surface characteristics
Finger pads Assess fine discrimination and sensations on the surface areas such as texture, shape, consistency, pulses and crepitus
Dorsal surface of the hand The back of the hand is used to assess temperature
Ulnar surface or ball of the hand Assess vibrations, fremitus (vibration on the body) and thrills (vibration over the chest wall)
Light Palpation to touch and feel for surface characteristics- gently press down 1 cm or 1/2 inch- use light circular motions to palpate for texture, masses and tenderness
Deep Palpation To assess for location and size of internal organs, masses and tenderness- gently press down about 5cm or 2 inches – assess for organ size and location, masses and tenderness
If pain is reported in an area when do you palpate that area? Palpate that area last
Percussion Percussion creates a sound wave that vibrates; different tones are elicited depending on the underlying tissue density
Direct Percussion To assess the size, consistency, and boarders of body organs, and the presence or absence of fluid in body areas- use only one or two fingertips, directly and lightly tap on the area that needs to be assessed – listen carefully for the sound to identify characteristics
Soft Tones heard over solid tissue
Moderate tones heard over fluid filled areas
Loud tones heard over air-filled spaces
Tympany heard over abdominal areas that may be filled with abdominal gas or air-filled structures
Dullness heard over solid organs, fluid collection, or areas of consolidation (such as tumor or mass)
Resonance Heard over normal lung fields
Hyperresonance heard over air-filled spaces such as lung fields in a patient with emphysema
Flatness heard over increased tissue density such as bones
Indirect Percussion To assess the size, consistency, and borders of body organs, and the presence or absence of fluid in body areas- Lay your middle finger of your non-dominant hand on the area being assessed- flex the wrist of your dominant hand and tap your middle finger of this hand on the interphalangeal joint of the middle finger of your non-dominant hand to elicit a sound
Indirect fist percussion (blunt percussion) To assess organ tenderness- lay your non dominant hand over the area being assessed- make a fist with your dominant hand-Using the ulnar surface of your closed fist and using moderate intensity, hit the dorsum of the non dominant hand- discomfort indicates kidney inflammation
Auscultation To listen to cardiovascular, respiratory, gastrointestinal and peripheral vascular sounds
Direct Auscultation To listen to the sounds produced by the body- place ear near exposed area- listen for about a minute for sounds
Indirect Auscultation To listen to sounds produced by the body with an amplification device- place stethoscope over area to be assessed
Where is the Bell of the stethoscope used best? Best to hear low-pitched sounds- vascular sounds, and heard murmurs
Where is the diaphragm of the stethoscope used best? Best used to hear high pitched sounds- respiratory ot gastrointestinal
Temperature Body temperature is regulated by the thermoregulatory center in the hypothalamus that balances heat production and heat loss
Pulse Rate Reflects heart rate/ number of time your heart beats per minute
Respiratory Rate Located in the medulla oblongata and pons in the pons in the brain stem
Blood Pressure The force of blood being exerted on the walls of the arteries as it is being pumped out of the heart
Assessing temperature To assess the bodys core temperature
Assessing oral temperature Normal findings: 97.5-99.5Abnormal findings: less than 97.5 or greater than 99.5The oral temperature should not be used on a patient who cannot follow directions, has decreased mentation or breathes through his or her mouth Assessing tympanic temperature Normal findings: 98.2-100Abnormal findings: less than 98.2 or greater than 100 Should not be used on a patient who is experiencing ear pain, ear drainage or has large amounts of wax in the ear
Assessing temporal temperature Normal Findings: 98.7-100.5Abnormal Findings: less than 98.7 or greater than 100.5
Assessing Rectal temperature Normal Findings: 98.7-100.5Abnormal Findings: less than 98.7 or greater than 100.5* should not be taken on a patient who had rectal surgery, disease of the rectum, low wbc count, blood clotting disorders, neurologic disease, cardiac disease, diarrhea, hemorrhoids
Palpating the radial pulse To assess heartbeat throughout the wall of the radial peripheral artery at the wristNormal findings: resting pulse 60-10o. rhythm: regular. amplitude: +2Abnormal findings: pulse less than 60 or greater than 100Rhythm: irregular with pausesAmplitude: absent, weak, bounding
Bradycardia heart rate less than 60 bpm
Tachycardia Heart rate grader than 100 bpm
Arrhythmia irregular heart rate
Auscultating the apical pulse Normal Finding: 60-100 bpm, rhythm: normalAbnormal Finding: Less than 60 or greater than 100, rhythm is irregular with pauses
Pulse Deficit difference between the apical and radial pulse rates
Assessing Respiratory Rate To assess the pulmonary ventilationNormal Findings: 12-20 bpmAbnormal Findings: less that 12 bpm or more than 20 bpm
Dyspnea difficulty breathing
Assessing blood pressure in upper arm To assess circulatory blood volume as the heart contracts and relaxesNormal: less than 120/less than 80
Hypotension blood pressure that is below normal limits
Pre hypertension 120-129/ 80
Stage 1 hypertension 130-139/80-89
Stage 2 hypertension 140-149/90-99
orthostatic hypotension Low blood pressure that occurs from lying down or when you stand up from a sitting position
Acute Pain short term
Chronic Pain long term
Intractable pain constant
Intermittent Pain Comes and goes
Cutaneous Pain originates from skin and subcutaneous tissue; it is a superficial pain
Colicky Pain fluctuates in intensity from severe to mild and most often occurs in waves; usually related to spasms in the intestines
Nociceptive Pain results from damage or inflammation to the sensory nerves in soft tissues; it may be described as dull, sharp or achy pain
Somatic Pain a diffuse, sharp and well localized pain
Visceral Pain is vague or poorly localized and usually originates from internal organs
Neuropathic Pain Caused by injury or damage to nerves; this pain feels sharp, stings, burns and the patient may experience numbness and tingling sensation
pshychogenic pain has no organic structural cause
Radiating Pain Starts in one area and spreads out to another part of the body
Referred pain Felt in an area away from the actual source of the pain
Epidermis Outer layer of the skin
Dermis middle later of the skin
subcutaneous layer innermost layer of the skin, containing fat tissue
lunula a crescent-shaped whit opaque area near the nail root
Nailbeds pink due to highly vascular epithelial cells
Sebaceous glands Located over the entire body except on the palms of the hands and soles of feet. Produces and secretes a protective oil through the hair follicles called sebum
Eccrine glands A type of sweat glands that produce an odorless fluid to maintain body temperature and produces sweat
Apocrine glands A sweat gland that produces a body odor when reacting to bacterial decomposition and increases in response to emotional stress; located in the axillary and genital regions
Acne an inflammatory disease of the sebaceous follicles of the skin, marked by comedones, papules, and pustules
Cancer a malignancy of the cells
Eczema A chronic inflammatory skin disorder that causes the skin to become scaly, itchy, inflamed, and irritated
Psoriasis A chronic immune disorder that causes the skin to develop silvery, scaly plaques
Seborrhea dermatitis An inflammatory skin condition causing flay, yellow, scale to form on the scalp, ears and face
Albinism Inherited disorder caused by the total or partial absence of an enzyme that produces melanin
Carotenemia A yellowing of the skin due to increased dietary intake of carotene in the diet, from foods such as carrots, sweet potatoes, pumpkin, corn, yams, spinach, and beans. the sclera of the eye does not become yellow
Central Cyanosis Bluish discoloration to the skin related to decreased circulating oxygen; best asses in the oral mucosa, conjunctiva of the eyes, lips and tounge
Erythema Red, pink skin color; may indicate inflammation, fever, or increased blood flow. In carbon monoxide poisoning, the individual will have a bright red cherry face and upper trunk
Hyperpigmentation darker skin color
hypopigmentation lighter skin color
Jaundice Yellowing of the skin due to excessive levels of bilirubin in the blood
Pallor/pale pale skin is seen in anemia, a decrease in circulating red blood cells or blood flow, or absence of oxygenated blood
Peripheral Cyanosis A blue, grey, slate, or dark purple discoloration of the skin or mucous membranes caused by deoxygenated or reduced hemoglobin in the blood; may occur with decreased cardiac output
Vitiligo Autoimmune disorder that causes smooth, white patches of skin all over the body
Rosacea an inflammatory skin condition causing redness, swelling and spider-like blood vessels to develop on the middle of the face
Macule a circular, small, flat spot less than .5cm in diameter. Macules are red, brown, or white in color, and the color is not the same as nearby skin
Patch irregular, flat, non palpable macule greater than 1cm
Paupule A solid, elevated spot that appears rough in texture and measures less than .5 cm in diameter
Vesicle A raised, round, or oval with serous blood or clear fluid measuring less than .5 cm in diameter
Tumor A solid, elevated and palpable measuring greater than ,5cm; may vary in shape and size
Wheal Defined by raised swelling, red bumps, or welts and itchy skin. Wheals are red in color and are usually caused by an allergic reaction
Nodule solid, elevated and palpable measuring less than .5cm
Telangiectasia Small, dilated blood vessels in the surface of the skin
Cyst Elevated, encapsulated and filled with fluid measuring 1cm or larger
Crust a dried collection of blood, serum or pus; part of the normal healing process
Scale A dry build up of dead skin cells that usually flaes off the surface of the skin
Exoriation a hollow crusted area with loss of the epidermis and in exposed dermis; may be caused by scratching the area
Erosion a depressed area that is moist and shiny, a loss of the superficial epidermis
Fissure a linear break in the skin that involves the epidermal and dermal layers
Ulcer a concave, exudative and variable in size. ulcers erode different laters of the skin
Scar a discolored fibrous tissue that appears over healed surgical incisions and wounds
Keloid Created by excessive collagen production extending beyond the original boundaries of a wound or incision
Hyperhydrosis Is excessive sweating of the body or hands, palms, armpits, feet or due to an increased number of sweat gland
Diffuse/generalized lesions distributed over the entire body as in hives or allergic reactions
Localized Lesions in a very limited, discrete area
Scattered lesions that are sparsely distributed as in seborrheic keratosis. Seborrheic keratosis are brown to black skin growths that can occur due to the aging process
Regional Confined specifically to one body area
dermatome Area of skin supplied by a single spinal nerve
Mole Neumonic A- asymmetryB- BorderC- ColorD- DiameterE- evolving
Ecchymosis a bruise caused by bleeding under the skin or mucous membranes; occurs as a result of local trauma
Hematoma an elevated collection of clotted blood within the tissue caused by a break in a blood vessel
Petechiae tiny, pinpoint hemorrhages caused by superficial bleeding from the capillaries of the skin
Purpura hemorrhagic red or purple spot or rash that is flat and does not blanch
Alopecia hair loss
Folliculitis inflammation of the hair follicles
Hirsutism excessive hair growth over the body
Beau’s line a white horizontal groove across the nail bed, usually caused by disease, toxin reaction or trauma
onychomycosis a thickening yellow discoloration and scaling of the nail bed due to a fungal infection
Paronychia a skin infection around the nail causing erythema, swelling and tenderness at nail fold
Pitting a sign of psoriasis
Splinter Hemorrhages appear as red streaks in the nails caused by bleeding from capillaries under the nails
Spoon nails Are flat or concave; outer edges flare out
Stage 1 pressure ulcer nonblancable erythema of intact skin
Stage 2 pressure ulcer partial thickness tissue loss involving both epidermis and dermis
Stage 3 pressure ulcer Full thickness tissue loss involving the subcutaneous tissue
Stage 4 pressure ulcer Full thickness tissue loss with extensive involvement of muscle or bone, or supporting structures
Turbinates Flaps of skin on outer edge of each nare
Rhinitis Inflammation of the the mucosa in the nose causing nasal congestion and sneezing
angular cheilitis inflammation at the corners of the mouth
Angioedema edema of the lips; usually related to an allergic reaction
Herpes Simplex Virus manifests with cold sores or blisters on the lips
Thrush a fungal infection that creates thick, white to yellow patches on tongue and basal mucosa
Atrophic glossitis a smooth red or pink tongue; may indicate nutritional deficiencies
Hairy Tounge a white to dark overgrowth, may indicate systemic immune suppression or too much bacteria
Leukoplakia Patches on tongue usually white or grey that may progress to cancer
squamous cell carcinoma presents as a thickened white or red patch or plaque
Tonsilitis a viral or bacterial infection of the tonsils; tonsils become enlarged, swollen and may have white or yellow drainage
Pharyngitis a sore throat caused by inflammation of the mucous membranes of the back of the throat
Torticollis A stiff neck with muscle spasm of the sternocleidomastoid muscle on one side of the body causing a lateral flexion contracture of the cervical spine musculature
Audiometric testing a hearing evaluation to assess conductive and sensorineural hearing loss at different high and low frequencies
Tympanometry assesses the movement of the tympanic membrane and disorders of the middle ear
Tinnitus “the perception of sound when no actual external noise is present. Commonly referred to as “”ringing in the ears”””
Cauliflower ear occurs from repeated trauma or hitting the ear
Microtia a congenital deformity; the pinna is underdeveloped
Macrotia abnormally large ears
Tophi hard, white or cream colored, non-tender deposits of uric acid crystals indicative of gout
Conductive hearing loss when sound is not conducted through the outer ear canal to the eardrum and the ossicles of the middle hear
sensioneural hearing loss Inner ear hearing loss occurs when there is damage to the cochlea or to nerve pathways to inner ear
Mixed hearing loss includes both conductive and sensorineural hearing loss
The Weber test to assess unilateral hearing loss and functioning of the cochlear nerve
The Rinne test to assess hearing by bone conduction versus air conduction and middle ear disease
Earwax (cerumen) a moist or dry, waxy substance that acts to protect the skin of the external ear canal from water damage, infection trauma and foreign bodies
Otits externa inflammation of the outer ear causing redness, inflammation, discharge, and pain
Otitis media inflammation of the inner ear causing pain, inflammation, pressure, and a build up of fluid; bright red bulging eardrum or no cone of light visible
Serous otitis media an accumulation of fluid in the middle ear caused by an obstruction of the eustachian tube
Otomycosis a fungal infection of the external auditory canal; black and white dots will be present in the ear drum and canal
Otalgia ear pain
Otorrhea ear drainage
Scarred tympanic membrane less blood supply and appears to have white, dense, streaks and spotting
Perforated tympanic membrane a ruptured tympanic membrane, a dark oval, hole will be present in the membrane
conjuctiva thin membrane covering the front eye and inner eyelids
Sclera white avascular tissue that protects the eye and maintains the shape of the eye
intraocular muscles six small muscles connect to the sclera to control eye movements, secure the eyeball in the sockets and allow sight in different directions
Tonometry A device to measure intraocular pressure
cataracts are a clouding of the lens that causes blurry, decreased or loss of vision
Glaucoma a buildup of intraocular pressure that damages the eyes optic nerve causing loss of peripheral vision
Macular Degeneration a deterioration of the central part of the retina causing loss of central vision
Loss of visual acuity refers to the inability to see objects clearly
Loss of visual field refers to the inability to see from side to side or up and down without moving the eyes or turning the head
Farsightedness (hyperopia) difficulty focusing on near objects;
Nearsightedness (myopia) distant objects appear blurred
Ptosis drooping of the eyelid caused by muscle or nerve dysfunction, injury or disease
Blepharitis an inflammation and infection of the eyelid margins. the eyelid margin becomes red, crusty, and greasy due to too much oil being produced by the eye glands
Blocked Lacrimal duct causes excessive tearing because tears cannot drain properly
Conjunctivitis a bacterial or viral infection causing erythema of the sclera and yellow-green drainage of the conjunctiva
Corneal abrasion a painful scratch to the clear surface of the eye, usually related to trauma to the eye
Ectropion everted eyelid
Entropian inverted eyelid
Exophthalmos a protrusion of the anterior portion of the eyeball
Hordeolum A stye, an infection of a follicle of an eyelash that causes redness, inflammation and a lump at the site
Scleral jaundice a sign of elevated bilirubin in the blood
Pterygium a gelatinous, abnormal growth of the conjuntiva
Periorbital edema swelling in the tissues of the eye
presbyopia inability to focus clearly on near objects
Legal blindness visual acuity of 20/200 or more
How to assess for visual acuity Use the snellen chart and stand 20 feet from chart
How to assess for color blindness Used the Ishihara plates
How to assess for central vision/macular degeneration The amsler grid test
Scotoma an area of reduced or absent vision surrounded by an area of normal vision
Hemianopia When half the vision field is lost
dilopia double vision
Nystagmus an involuntary, cyclical movement of the eyes
Anisocoria unequal size of pupils
Mydriasis a bilateral dilated and fixed pupils
Horner Syndrome a sign of medical condition that affects one side of the face; drooping eyelid, constricted pupil
Pulse Oximeter measures the oxygen saturation
Arterial Blood Gases Measuring the levels of oxygen and carbon dioxide in the blood
thoracentesis an insertion of a needle into the thoracic cavity; the test is performed for analysis or removal of fluid from the pleural space for diagnostic or therapeutic purposes
Bronchoscopy a diagnostic or therapeutic procedure that provides direct visualization of the larynx, trachea and bronchial tree
Lung biopsy removes small piece of lung tissue from analysis
Asthma a reactive airway disease causing inflammation increased mucus production and narrowing of the bronchi; symptoms include cough, confession, shortness of breath and wheezing
COPD an obstructive and progressive lung disease causing inflammation and destruction of the lung tissue; symptoms include shortness of breath and congestion
Cystic fibrosis a hereditary disease of the exocrine glands; the body produces abnormally thick and sticky mucus that obstructs the lungs and digestive organs
Bronchitis a viral or bacterial infection causing inflammation of the bronchi; the most common symptoms are fever, cough, and lung congestion
pneumonia a viral, bacterial or fungal infection of the lung causing inflammation and congestion in the alveoli of the lung; symptoms include fever, cough, congestion and shortness of breath
Dyspnea Difficult breathing
Orthopena Difficulty breathing while laying in the supine position
Paroxysmal nocturnal dyspnea shortness of breath while sleeping
Pursed lip breathing breathing through the nose and exhaling through the pursed lips
Bradypnea abnormally slow respirations. Respirations less than 12
Tachypnea abnormally rapid respirations. Respirations greater than 20 bpm
Kussmaul Respirations respirations that are regular but abnormally deep and increased in rate
Biot respirations irregular respirations of variable depth alternating with regular or irregular periods of apnea; also called ataxic breathing
Cheyne-Stokes respiration Gradual increase indepth of respirations, followed by gradual decrease and then a period of apnea
apnea absence of breathing
Clubbing of nail plates Occur with chronic lack of oxygen or hypoxia
Crepitus a light crackling or popping feeling under the skin caused by leakage of air into the subcutaneous tissue; sounds like rice krispies
Palpating tactile fremitus to palpate voice sound vibrations through the bronchi
Increased fremitus may indicate increased density of the lung tissue; may be related to fluid or pathology in the lung that is changing the density or compressing the lung tissue, such as pneumonia
Decreased fremitus may indicate the vibrations are obstructed with fluid (pleural effusion), decreased air movement (emphysema)
Dullness sounds are soft and muffled and heard over areas of increased density
Hyperresonance A low-pitched, drumlike, accentuated percussion sound heard in the lungs when the bronchi and alveoli are overinflated as in emphysema and asthma
Diastole a period of time that the heart relaxes and fills with blood, decreasing blood pressure in the arterial system
Systole a period of time that the heart ventricles contract and push blood out into the arterial systems
Cardiac output the amount of blood the heart pumps out in 1 minute
What region does the liver lie in? the liver occupies almost the entire right upper quadrant
What enzymes exist largely in the liver? AST and ALT. A rise in these enzymes indicate injury to the liver
Bilirubin Primarily produced in the liver, spleen and bone marrow. An increase in bilirubin deposits a yellow pigment in the skin and sclera.
Where doest the gallbladder lie? The right upper quadrant
What are the two primary functions of the pancreas? Endocrine function that secretes insulin and exocrine function that releases pancreatic juice
What are the digestive enzymes of the pancreas? Amylase and lipases. Elevations of these enzymes may indicate obstruction, inflammation or early pancreatic cancer
What quadrant is the stomach in? The stomach is in the left upper quadrant
What quadrant is the spleen in? The spleen is in the left upper quadrant
Stool Analysis an examination of feces for volume, odor, shape, color, consistency, and presence of mucus, pathogens and substances
Fecal Occult blood test A test for hidden occult blood in the stool.
Blood Urea Nitrogen (BUN) blood test that measures the amount of urea in the blood
Creatinine If the waste products are accumulating and are not excreted by the kidneys, creatinine levels rise
Dysphagia Difficulty Swallowing
Pyrosis “Indigestion/heartburn usually described as a “”burning sensation”” in the epigastric area radiating up the throat”
Dyspepsia A vague feeling of fullness and chest discomfort, indigestion, or burning in the chest or upper abdomen, especially after eating
gastroesophageal reflux disease (GERD) a motility disorder characterized by heartburn and reflux of gastric content into the lower esophagus
Parietal Pain a steady, sharp, localized and intensifies with movement; usually caused by inflammation of the parietal peritoneum
Peritoneal Pain caused by peritoneal inflammation produces localized, sharp or generalized abdominal tenderness
bilious vomiting green-yellow bile related to a biliary obstruction
Black vomit vomit containing blood acted on by gastric digestion
Coffee ground vomit appearance and consistency of coffee ground mateiral; may have blood mixed in with the vomitus
Hematemesis vomiting of blood
Projectile Vomiting without nausea sign of central stimulation of the medulla; could be a sign of brain pathology or head trauma
Dysuria painful or difficult urination indicative of an inflammatory condition or pathology of the urinary tract
Renal Colic Pain results from a kidney stone
Aneurysm a weakening and out pouching of an artery
Ascites an abnormal accumulation of fluid in the peritoneal cavity
diastasis recti a bulging area in the abdomen occurring with the seperation of the two halves of the rectus abdomonis muscles in the midline
Hernia protrusion of an organ through the abdominal wall
Hyperactive bowel sounds high-pitched bowel sounds
Hypoactive bowel sounds soft, irregular sounds may indicate early bowl obstruction or increased peristalsis
borborygmus loud-gurgling or rumbling sounds made by the movement of gas through the intestines
Portal Hypertension an increase in pressure in the portal vein caused by an obstruction in the blood flow through the lover
Bruits turbulent, blowing sounds heard over a partially or totally obstructed artery. Most commonly a build up of plaque in the artery
Venous Hum continuous medium-pitched sound caused by turbulent blood flow in a large vascular organ
Friction Rub a grating sound heard over inflamed organs with serous surfaces
Distended bladder is palpated as a smooth, round, and firm mass extending as far up as the umbilicus. A person with a distended bladder may have difficulty urinating or will release only small amounts of urine
percussing costovertebral tenderness to assess tenderness or inflammation of the kidney
Paracentisis The procedure to remove fluid from the peritoneal cavity by inserting a needle into the cavity for diagnostic evaluation
Angiogram an x-ray that uses special dye to visualize blood flow through arteries or veins
Angioplasty a balloon is places in the blocked area and inflated to break up the plaque, widen the diameter of the artery and increase blood flow
peripheral arterial disease (PAD) a term used to describe narrowing or occlusion by atherosclerotic plaques of arteries outside the heart and brain
Intermittent claudication a cramp like pain felt in the buttocks, thighs or calves during exercise or walking due to decreased blood flow and oxygen to legs
Lymphedema an accumulation of lymph fluid in the tissues
Raynaud’s disease a result of cold induced vasospasm of the small blood vessels in the fingers and toes, causing blanching, cyanosis or redness of the hands and feet
Loss of hair on the extremities Decreased circulation causes hair loss in the affected extremity and rough, scaly, flaky skin
Coolness of extremities Loss of circulation causes coolness of the extremity
Decreased wound healing decreased circulation causes poor or delayed wound healing
Abnormal findings of lymph nodes greater than 1 cm, rock hard, fixed or matted, tender nodes
A thrill an abnormal tremor accompanying a vascular murmur
Cellulitis a bacterial infection of the skin and subcutaneous tissue: the skin appears red and swollen; feels warm hot and tender
Edema an accumulation of fluid seeping into the tissues
varicose veins protruding veins of the lower extremities; resulting from incompetent values; pooling of blood in the veins
Joints Connects bones together
Synovial joint has a joint capsule that keeps the synovial fluid in the joint. serves to lubricate and provide nutrients to the joint
Nonsynovial joints Joints will not have synovial fluid
Fused joints found primarily in the skull; these joints are irregular and flat
ball and socket joint allows for greater movement and are found in the shoulder and hip
Hinge found in the elbow, finger, knee and toes
Gliding Found in the wrist, hand, ankle and foot
Plane Found primarily in the vertabrae
Condyloid found primarily in the wrists
Abduction movement away from the midline
Adduction movement toward the midline
Pronation a rotational movement away from anatomical neutral
Supination is rotational movement toward the anatomical neutral
Eversion Moving away from the midline of the body
Inversion moving toward the midline of the body
Dorsifelxion upward flexion of the foot
Plantar flexion downward flexion of the foot
Flexion moving toward the body
Extension Moving away from the body
Elevation movement that raises a body part in its plane
What is it called when a tendon is injured? Strain
What is it called when a ligament is injured? Sprain
Creatine phosphokinase (CPK) a blood test that shows increased CPK enzyme levels when muscle tissue is injured. Elevation indicated an injured muscle
Osteoarthritis a progressive disease; the protective cartilage at the ends of the bones wear down. More commonly in women
rheumatoid arthritis a progressive, inflammatory autoimmune disorder that affects the smaller synovial metacarpophalangeal and interphalangeal joints
Osteoporosis A progressive disease; the bone matrix is not being replaces by new bone ad bone mass and density decrease
What are the 5 P’s of pain? PainparalysisParesthesiaPallorPulselessness
ataxia an unsteady gait that may be used to compensate for injury or pain in the extremities. May also indicate a problem with cerebellar function
Scissor gait most commonly seen in cerebral palsy. the legs cross the midline in a swinging fashion to compensate for lack of motion
Shuffling gait may indicate a problem with balance, parkinson’s disease or decreased lower extremity strength
Foot Drop weakness or paralysis of the muscles of the leg or the inability to control plantar flexion of the ankle
Scoliosis an abnormal curvature of the spine that occurs in a lateral manner may look like a C or S
Kyphosis a curvature of the spine that looks like slouching or hunchback posture. This occurs in the thoracic spine
Lordosis a curvature of the spine that looks like an arched lower back and increased inward curvature of the lumbar spine
Bouchards Nodes bony enlargements of the proximal interphalangeal joints
Heberdens nodes bony enlargements of the distal interphalangeal joints
Radial Deviation movement of the hand toward the radial head
Ulnar deviation movement of the hand toward the ulnar head
Tinel’s sign tap the median nerve; if the patient complains of tingling or pain radiating to the thumb= positive tinel sign
Phalen’s test patient flexes both wrists downward with fingers pointed downward if patient feels tingling or numbness = positive phalens test
Carpal Tunnel Syndrome compression of the median nerve
Hallux vagus (bunion) a lateral deviation and enlarged joint of the great toe
Hammertoe permanent contracted toe deformity
CN I Olfactory
CN II optic
CN III Oculomotor
CN IV Trochlear
CN V Trigeminal
CN VI Abducens
CN VII Facial
CN VIII Acoustic
CN IX Glossopharyngeal
CN X Vagus
CN XI spinal accessory
CN XII Hypoglossal
Electroencephalogram (EEG) sensors are attached to the head to measure electrical activity of the brain; used to diagnose seizure activity and neurological disorders
Lumbar Puncture Insertion of a needle into the subarachnoid space of the vertebrae to withdraw cerebrospinal fluid for analysis
Cerebral angiography dye is injected in the femoral arteries to assess cerebral circulation
Meningitis inflammation and infection of the meninges caused by a virus, fungus or bacteria
Neuropathy loss of sensation that may feel like numbness, tingling, or the inability to feel
Neuropathies occur when nerves of the peripheral nervous system are damaged, caused by peripheral vascular disease, tissue ischemia and diabetes. Symptoms may include tingling, numbness, a burning sensation, pain or muscle weakness
Transient Ischemic attack (TIA) temporary loss of blood flow to the brain
Dysphasia partial impairment of language and speech impacting the ability to communicate
Aphasia Complete impairment of comprehension and expression in the verbal, written and signed modalities. Patients have difficulty with speech, understanding language and difficulty reading and writing
Migrane throbbing or pulsing head pain often confined ot one side of the head with sensory sensitivity, such as light, sound and movement
Tension headache Episodic generalized pain, feels like pressure around the circumference of the head
cluster headache Unilateral one-sided burning, stabbing, piercing pain. May have swelling or redness around affected eye
receptive aphasia damage to wernickes area; unable to understand language in written or spoken form
Expressive aphasia damage to broca’s area; unable to communicate language in written or spoken form
Hypoxia lack of oxygen supply
Paresthesia numbness or tingling of the extremities related to decreased circulation
Myasthenia lack of muscle strength or muscle tone
Myasthenia gravis a chronic autoimmune neuromuscular disorder that causes weakness of the voluntary muscle groups
Multiple Sclerosis Inflammatory nervous system disease; the mylein of the nerve cells of the brain and spinal cord are damaged causing decreased nerve transmission and communication between the brain and body
Lethargic difficulty maintaining mentation or mentation is sluggish; patient is arousable and able to answer questions
Obtunded able to only keep the patient awake by verbal or tactile stimuli; patient is confused when awake
Stupor patient is unresponsive to verbal stimuli with decreased responsiveness to painful stimuli; nonverbal if patient opens eyes
Comatose lack of response to any stimuli
Anosmia inability to smell or identify the correct scent, indicating loss of function to olfactory nerve
Hypotonia decreased tone and may be seen in neuromuscular disorder
Flaccidity loss of muscle tone
Hypertonia increased muscle tone and may be result of injury to upper motor neurons
Rigidty muscles are contracted and tense; associated with Parkinson’s disease and neuromuscular injuries or disease
Spasticity increased motor tone causing stiffness and tight muscles
Hemiparesis loss of muscle tone, strength to unilateral side of body
Parapalegic absence of movement and sensation in lower extremities
Quadriplegic absence of movement and sensation in upper and lower extremities
Decorticate Posturing Consists of internal rotation and adduction of the arms with flexion of the elbows, wrists and fingers; plantar flexion of the feet with internal rotation; both legs are stiffly extended; indicates severe brain injury
Decerebrate posturing consist of arms stiffly extended, adducted, and hyperpronated with hyperextension of the legs and plantar flexion of the feet; legs are stiffly extended; indicated more serious damage in midbrain of brainstem
Dysmetria inability to preform point-to-point movements due to over or under projecting the finger to touch an object
Dysdiadochokinesis Uncoordinated, slow, and clumsy movements; may be a sign of cerebellar disease, Parkinson disease and multiple sclerosis
Parkinson Disease a Progressive movement disorder caused by decreasing amounts of dopamine being produced in the brain; this causes a person to be unable to control movement normally
Pronator Drift test To assess motor function and proprioceptionNegative pronator drift: arms should remain in the extended position without drifting Positive Pronator drift: an arm does not remain raised, the palm may pronate or drop slightly
Romberg test To assess position sense and cerebellar function, balance, and coordination Negative Romberg test: maintains position without swaying or loss of balance, with and without opening eyesPositive Romberg test: swaying or loss of balance with or without eyes open may indicate cerebellar dysfunction or lesions in the cerebellum or spinal cord
Assessing graphesthesia to assess the sensation of touch or tactile stimulation
Assessing sterognosis to assess the perception of a shape or object
Tactile Agnosia the inability to process sensory information and to perceive and recognize an object by touch
Clonus a repetitive, rhythmic, uncontrolled reflex response caused by several neurological disorders
perimenopause may occur several years prior to menopause
Menopause occurs when the women has no menstural activity for a period of 12 months
Postmenopause the period of time after menopause when menopausal symptoms start to diminish
Mammogram one of the best screening tests to detect breast cancer; it is a film x-ray of the internal structures and tissues of the breasts
Sonogram a breath ultrasound that uses sound waves to take pictures of breast tissue
Papanicolaou test (pap smear) a screening test to detect abnormal cervical cells including cervical cancer
Human Papillomavirus (HPV) test screening for the HPV infection
Vaginal Specimans Obtained in woman with vaginal discharge; the specimen identifies the organisms causing symptoms
Amenorrhea absence of menstruation
Primary amenorrhea defined in women who are 15 years and older and have not had a menstrual cycle
Secondary amenorrhea the absence of a menstrual cycle for more than 3 months in girls or women who previously had a regular menstrual cycle for six months in girls or women who had irregular menses
Metrorraghia uterine bleeding at irregular intervals most often associated with dysfunctional ovaries
Menorrhagia excessive or prolonged duration of menses; may pass many clots with menstrual flow
Oligomenorrhea decreased or light menses
Primary dysmenorrhea menstrual pain occurring with ovulatory menstrual cycles
Polycystic ovarian syndrom (PCOS) an endocrine disorder in women of reproductive age that can cause irregular menstrual cycles
Premenstrual syndrome (PMS) a group of symptoms occurring 1-2 weeks prior to menstruation
Fibrocystic breast disease is a benign painless lump or thickening of tissue that are felt in a womens breast
Breast cysts are fluid filled lumps in the breast; may or may not be painful
Fibroadenomas solid, round, rubbery lumps filled with fibrous and glandular tissues; these lumps move easily when pushed
Mastectomy the surgical removal of one or both breasts
Breast reduction surgery Removes breast tissue and skin to reduce size of the breasts
Breast Augmentation a surgical procedure to increase the size of one or both breasts
Supernumerary nipple an additional nipple
Mastitis redness and inflammation of the breast tissue often occurring in the postpartum period when breast feeding
Peau d’orange pitting, dimpling, or swelling seen in inflamed skin that overlies inflammatory carcinoma of the breast
Nipple Discharge normally seen in pregnant woman and one who is breast feeding an infant
Paget’s disease a type of breast cancer that may occur in the areola area
Pediculosis pubis presence of lice or nits
urethra caruncle a benign fleshy outgrowth at the urethral meatus
prostate-specific antigen (PSA) blood test that measures the level of prostate-specific antigen in the blood
Gonorrhea inflammation of the urethra, prostate, rectum and or pharynx
Chlamydia an STI caused by bacteria. Symptom in men is penile discharge and painful urination
Testicular pain may be related to trauma, infection or cancer
testicular torsion occurs when the testicle twists inside the scrotum; decreasing the blood flow to the scrotum and causing severe pain; this is a surgical emergency
Benign prostatic hypertrophy (BPH) a non malignant enlargement of the prostate gland as part of the aging process
Hydrocele an accumulation of fluid around the testes
epididymitis swelling and inflammation of the epididymis
Genital herpes an STI caused by herpes simplex virus. painful fluid filled blisters or vesicles
Human Papillomavirus (HPV) the virus destroys the cells of the immune system and progresses and causes AIDS
human immunodeficiency virus (HIV) an STI viral infection caused by retrovirus causing general flu-like symptoms. Progresses to AIDs
Syphilis STI and initial symptom is a sore called a chancre
Glynecomastia an enlarged or over developed fibroglandular breast tissue
condyloma acuminatum genital warts
hemorrhoids swollen, dilated veins that protrude from the lower rectum or anus
Melena black tarry stool