The nurse is preparing to conduct a health history. Explain this to the patient.
Answer- The purpose of a health history is to provide a database of subjective information about the patient’s past and current health history. You might say to the patient, “I will be asking you questions about your past and present health.” This information will help the provider along with the physical exam (objective data) to develop a diagnosis or health status.
The nurse is evaluating the reliability of a patient’s responses, which of these statements would be correct? The patient:
Provided consistent information and therefore is reliable
A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse’s best response?
“Can you point to where it hurts?”
A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be the nurse’s appropriate response to the woman’s statement?
“How would you say the pain affects your ability to do your daily activities?”
A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information?
“Describe what happens (or the reaction) to you when you take Penicillin.”
The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:
Mental illness.
The review of systems provides the nurse with…
Information regarding health promotion practices, the information helps to evaluate the past and present health state of each body system, to obtain any data that may have been omitted in the section about present illness, and to evaluate health promotion and teaching opportunities.
Which of these statements represents subjective data the nurse obtained from the patient regarding the patient’s skin?
Patient denies any color change.
The nurse is obtaining a history from a 30-year old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
“Do you perform testicular self-examinations?”
Functional Assessment– What information would you ask if the patient’s leg was in a cast?
A functional assessment includes the activities of daily living and the person’s ability to take care of their needs. This area will help to formulate a nursing diagnosis. This could be present to the patient in a standardized form and will include data on the lifestyle and type of living environment. (Page 57) self-esteem, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships/resources, spiritual resources, coping and stress management, personal habits, environmental hazards, violence questions, and occupational health questions. If a patient had a cast on their leg, appropriate questions would include how they transfer to bed, another chair, bathing technique, coping with the situation, support during the situation.
Regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason why?
Alcohol can interact with all medications and make some diseases worse.
Describe a genogram.
Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family. Usually 3 generations- parents, grandparents, siblings. Also highlight the health of close family members and more details such as communicable disease, environmental hazards (smoke), tobacco use, and alcohol use. Any additional information includes the family history.
The nurse is obtaining health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?
Current health promotion activities.
A 90-year-old patient tells the nurse that he cannot remember the names of the medication he is taking or why he is taking them. An appropriate response from the nurse would be..
Would you have a family member bring in your medications please?
The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask?
“Are you able to dress yourself?”
A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms?
“This pain happens every time I sit down to use the computer.”
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason why is…
This is the location for most breast tumors.
In performing an assessment of a woman’s elixir lymph system, the nurse should assess which of these nodes?
Central, lateral, pectoral, and subscapular.
The breast has extensive lymphatic drainage, 75% of the drainage drains into the axillary nodes. There are groups of axillary nodes central, pectoral and subscapular.
A 65-year-old patient remarks that she just cannot believe that her breasts “sag so much”. She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause:
The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in sagging (flat and gabby) breasts.
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse’s best course of action?
Explain that this is the result of hormonal changes (testosterone) and recommend a visit to their provider.
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse’s most appropriate response to this would be:
To seek more specific information about the pain, such as: When did you first notice it? Is the pain localized or all over? Is it painful to touch? Is the pain in relation to your menstrual cycle? Is the pain associated with activity or exercise?
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which questions would be important for the nurse to ask?
Where did the rash first appear- on the nipple, areola, or the surrounding skin? When did you first notice this?
During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms “do a much better job than I ever could to find a lump.” The nurse should explain to her that:
Breast self-exams may detect lumps that appear between mammograms
List risk factors for breast cancer
History of breast cancer – family history—first-degree relative
Medications such as estrogen and progestin combined
Certain tumor suppressor genes called BRCA1 and BRCA2 (inherited mutation)
Age
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding?
Asymmetry isnot unusual, but the nurse should verify that this change is not new
During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?
Whether the inversion is a recent change should be determined.
The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:
Slowly lift her arms above her head, and note any retraction or lag in movement.
The nurse is palpating a female patient’s breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?
Supine with the arms raised over the head
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period.
The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct
“BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations.”
A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem “flat and flabby.” The nurse’s best reply would be:
The decrease in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging.
A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it “was nothing to worry about.” The examination validates the presence of a mass in the right upper outer quadrant at 1 o’clock, approximately 5 cm from the nipple. It is firm, mobile, and non-tender, with borders that are not well defined. The nurse replies:
Because of the change in consistency of the lump, it should be further evaluated by the physician.
The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is?
On the same day every month.
During a discussion about BSEs with a 30-year-old woman, what statement by the nurse is most appropriate?
Examine your breast shortly after your menstrual period each month.
Peau d’orange-
Lymphatic obstruction causes edema, which thickens the skin and exaggerates the hair follicles; this creates a pigskin or orange peel look. Could be an indication of cancer.
Dullness-
A high-pitched muffled thud sound obtained by percussing over relatively dense organs such as liver or spleen, distended bladder, mass of adipose tissue
Tympany-
A high-pitchedmusical and drum like note obtained by percussing the surface of a large air-containing space, such as the abdomen
Resonance-
A low-pitched, clear, hollow note obtained by percussing over normal lung tissue
Hyperresonnance-
A low-booming note obtained by percussing over the adult lungs that have increased air such as with a patient who has emphysema, present with distended abdomen
Which structure is located in the left lower quadrant of the abdomen?
Sigmoid colon
Aneurysm-
defect or sec formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect (aortic aneurysm)
Dysphasia-
Difficulty swallowing
Anorexia-
Loss of appetite
Ascites
abnormal accumulation of serous fluid within the peritoneal cavity, associated with heart failure, cirrhosis, cancer or portal hypertension
Bruit-
blowing, swoishing sound her through a stethoscope when an artery is partially occluded
Hepatomegaly-
abnormally enlarged liver
Paralytic ileus-
complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction
Peritonitis-
inflammation of the peritoneum
Nurse suspects a patient has a distended bladder. How should the nurse assess?
Percuss and palpate the midline area above the suprapubic bone.
The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:
Decreased gastric acid secretion.
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
Peritonitis,
The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
“Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.”
Abdominal borborygmi-
Hyperactive bowel sounds
Percussion notes heard during the abdominal assessment may include:
Tympany, hyperresonnance, and dullness.
Causes of Abdominal Distention-
Obesity, Ascites, Air or Gas, Ovarian cyst, Pregnancy, Tumor
Before reporting silent bowel sounds, the nurse should listen for at least:
5 minutes
The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?
The nurse should:
Examine the tender area first.
State the rationale for performing auscultation of the abdomen before palpation or percussion.
Percussion and palpation may increase peristalsis, which gives a false interpretation of bowel sounds
Specific questions to ask a patient with abdominal pain for the past week
Describe the pain, is it in one spot, or does it move around, have the patient point to the area, when did it start, how long have you had the pain, is it constant or does it come and go, does it occur before a meal or after meals, describe the pain is it a cramping, burning, dull, stabbing, or aching pain, are there any changes associated with meals does the pain become worse or better, what have you tried to relieve the pain, what makes the pain worse, is the pain associated with your menstrual cycle
Right Upper Quadrant Organs-
Liver, Gallbladder, Duodenum, Head of Pancreas, Right Kidney and adrenal gland, Hepatic flexure of colon, Part of ascending and transverse colon
Left Upper Quadrant Organs-
Stomach, spleen, left lobe of liver, Body of Pancreas, Left kidney and adrenal, splenic flexure of colon, part of transverse and descending colon
Right Lower Quadrant Organs-
Cecum, Appendix, Right over and tube, Right ureter, Right spermatic cord
Left Lower Quadrant Organs-
Part of descending colon, Sigmoid colon, Left ovary and tube, left ureter, left spermatic cord
Midline-
Aorta, Uterus, Bladder
Specific questions you would ask a patient who is complaining of nausea and vomiting
How often, how much come up, color, odor, bloody, pain associated, any diarrhea, fever, chills, what did you eat in the last 24 hours, where, is there anyone else in the family with the same symptoms?
Functional units of the musculoskeletal system-
Joints
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called:
Ligaments
To jump rope, the should has to be capable of:
Circumduction
Articulation of the mandible and temporal bone is:
Temporomandibular joint
Palpation of the temporomandibular joint:
Anterior to the tragus
An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. How would you explain this to the patient?
With aging, the vertebral column shortens
The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. An action to prevent or delay bone loss in this group would be?
Perform physical activity, such as fast walking.
A patient states, “I can hear a crunching or grating sound when I kneel.” She also states that “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints.” The nurse should assess for signs of what problem?
Crepitation
A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms. The nurse should suspect:
Rotator cuff lesions
During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient complains of a pain going down his buttock into his leg. The nurse suspects:
Herniated nucleus pulposus
Changes with an aging adult
After 40, loss of bone matrix occurs more rapidly than new bone formation; postural changes occur with decreased height the most noticeable; decreased height is due to shortening of the vertebral column; may see kyphosis; a distribution of subcutaneous fat changes through life; there is a tendency to gain weight; loss of muscle mass; may see a shuffling pattern when walking, arms out to help balance; broader base of support; may hold hand rails and haul their body up with it; may lead with favored leg; may find the aging holding two hands on the rail
Osteoporosis-
your bones are living tissue that are continually growing and changing. Each day old bone tissue dissolves and is replaced with new bone tissue. As we age, the opposite begins to occur. When this happens bone can become weak and more likely to break even with the slightest bump. The bones of the wrist, hip, and spine are most often affected. There is no cure but there is treatment
Steps to bone health and osteoporosis prevention-
- Diet- milk products (low fat) with vitamin D, which is needed for absorption of calcium; Fish canned ones which are packed in their bones; Leafy green vegetables; Limit caffeine;
- Exercise- weight bearing a regular program of at least 3 times a week.
- Lifestyle- avoid smoking and excessive alcohol; seek help for depression
- Supplements as directed by your provider
Rheumatoid Arthritis-
Rheumatoid Arthritis is a chronic, systemic inflammatory disease of the joints and surrounding connective tissue. Inflammation of the synovial membrane leads to thickening; then to fibrosis, which limits movement; and finally leads to bony ankylosis. Symmetric and bilateral characterized by heat, redness, swelling, and painful motion of the affected joints; the patient may experience fatigue, weakness, anoxeria, weight loss, low grade fever, and swollen glands
Osteoarthritis-
(Degenerative Joint Disease) is a non-inflammatory localized, progressive disorder involving deterioration of articular cartilage and subchondral bone and formation of new bone (osteophytes) at joint surfaces. It occurs with aging nearly all adult age 60 or older have some signs of osteoarthritis. Asymmetrical involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling, bony protuberance, pain with motion, limitation with movement.
Adduction, Abduction, Flexion, Extension
- Adduction – movement of a body part toward the body’s midline
- Abduction – movement of a body part away from the body’s midline
- Flexion- describes the movement that decreases the angle between a segment and its proximal segment
- Extension- is the opposite of flexion, describing a straightening movement that increases the angle between body parts
The 2 parts of the nervous system are:
Central and Peripheral
Personality and ability to understand, crying easily, and becoming angry are associated to which lobe of the brain?
Frontal
A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?
Cerebellum
A 70-year-old woman tells the nurse that every time she gets up in the morning or after she’s been sitting, she gets “really dizzy” and feels like she is going to fall over. The nurse’s best response would be:
You need to get up slowly when you have been lying down or sitting.
During the taking of the health history, a patient tells the nurse that “it feels like the room is spinning around me.” The nurse would document this finding as:
Vertigo
When discussing seizures with a patient, the patient asks the nurse, “What is an aura?” How would you explain this to the patient?
“Do you have any warning signs before the seizure occurs?” An aura is a subjective sensation that preceded a seizure; may be auditory, visual or motor.
When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:
Positive Romberg Sign.
During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: “He can’t even remember how to button his shirt.” When assessing his sensory system, which action by the nurse is most appropriate?
Before testing, the nurse would assess the patient’s mental status and ability to follow directions.
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient’s response:
It is very ominous sign and may indicate brainstem injury.
Syncope, Vertigo, Seizure, Tremors, Paralysis-
Syncope -a sudden loss of strength, a temporary loss of consciousness (a faint) caused by a lack of cerebral blood flow
Vertigo- is a rotational spinning caused by neurological disease in the vestibular apparatus of the ear or the vestibular nuclei in the brainstem
Seizure- characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances
Tremors– an involuntary shaking
Paralysis—decreased or loss of motor power caused by problem with motor nerve or muscle fibers
Stroke or Cerebrovascular Accident (CVA)-
Blood flow is interrupted to a part of the brain, the most common type is an ischemic stroke (when a blood clot blocks a blood vessel in the brain) and less common is a hemorrhagic ( a blood vessel in the brain ruptures and causes bleeding).
Common symptoms of a stroke:
- Weakness or numbness in the face, arms, or legs, especially when it is on one side of the body
- Confusion, trouble speaking or understanding
- Changes in vision such as blurry vision or partial complete loss of vision in one or both eyes
- Trouble walking, dizziness, loss of balance, or coordination
- Severe headache with no reason or explanation
Paresis, Paraplegia, Quadriplegia, Hemiplegia
- paresis–weakness of muscles rather than paralysis
- paraplegia–symmetric paralysis of both lower extremities
- quadriplegia–paralysis of all four extremities
- hemiplegia–paralysis of one side of the body
Symptoms of Meningeal Inflammation-
Sudden fever, stiff neck, severe headache different than normal, nausea and vomiting, seizures, sleepiness, sensitivity to light
The nurse notices that a patient’s palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)?
Cranial Nerve 7- Facial
We have an expert-written solution to this problem!
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN _ and proceeds with the examination by ______.
Cranial Nerve 11- Accessory; asking the patient to shrug her shoulders against resistance
A patient says that she has recently noticed a lump in the front of her neck below her “Adam’s apple” that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):
Mobile and not hard
4 areas of the body where lymph nodes are accessible:
Head and neck, arms, inguinal area, and axillae
A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her?
More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
A patient has come in for an examination and states, “I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?” The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:
Parotid gland
A patient’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a _ sound that is heard best with the _ of the stethoscope.
Soft, whooshing, pulsatile; bell
A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has:
CVA or stroke
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
Firm but freely movable
The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
Nonpalpable
During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?
Using gentle pressure, palpate with both hands to compare the two sides
Visual accommodation-
Pupillary constriction when looking at a near object
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:
Constriction of both pupils occurs in response to bright light
A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:
The patient can read at 20 feet what a person with normal vision can read at 30 feet.
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?
Observe the distance between the palpebral fissures
A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have:
Macular degeneration
If your patient presented with an eye injury resulting in an emergency situation what symptoms would you expect to see that would prompt an emergency?
Loss of vision
Sclera is china white, although Blacks occasionally have a gray-blue or muddy color to the sclera. Also in dark-skinned people you normally may see _______________on the sclera.
Small brown merciless (freckles)
Extraocular muscles-
Cranial nerves 3, 4, and 6
Chronic Open-Angle Glaucome, Macular Degeneration, Cataracts, Presbyopia-
- Chronic Open-Angle Glaucoma–Increased intraocular pressure that leads to peripheral vision loss.
- Macular Degeneration–Breakdown of cells in the Macula or the Retina that leads to loss of central vision-the area of clearest vision.
- Cataracts–Lens opacity, resulting from a clumping of protein in the lens.
- Presbyopia–Loss of lens elasticity decreasing the len’s ability to change shape to accommodate for near vision.
During an assessment of a patient has had a head injury from a car accident, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?
Increase in the intracranial pressure
The nurse notes that the patient’s teeth are stained yellow and asks the patient about tobacco use. The patient states that he chews one bag of tobacco every other day. What health promotion concepts should the nurse include in the teaching plan?
Smokeless tobacco (SLT) contains cancer-producing chemicals, such as nitrosamines, that increase the risk of oral cancers (pharynx, larynx, and esophagus). Early signs of oral cancer should be discussed, as well as other effects of SLT use, such as gum recession, tooth discoloration, bad breath, nicotine dependence, and unhealthy eating habits. SLT is not a healthy alternative to smoking.
Using smokeless tobacco can be detrimental to a person’s health. The two types of SLT most commonly used in the United States are chewing tobacco and snuff. The largest group of SLT users is American Indian/Alaskan Native children, but SLT use is also high among young white males.
Pain is an early sign of oral cancer
What is the purpose of the ciliated mucous membrane in the nose?
Filters out dust and bacteria.
Salivary gland that is the largest and located in the cheek in front of the ear is the __ gland.
Parotid
The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?
Decreased ability to identify odors.
Questions to include in aiding adult health history-
- Any dryness in the mouth?
Xerostomia (dry mouth ) is a side effect of many drugs: antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, bronchodilators - Are you taking any medications? (prescribed and over the counter)
- Can you chew all types of food? Have you lost any teeth?
- Are you able to care for your teeth or dentures?
o Self-care may be due to a physical disability (arthritis), vision loss, confusion, or depression - Have you noticed a change in your sense of taste or smell?
How would you control a nosebleed?
Remain calm, sit up straight, lean your head forward, tilting your head back will cause you to swallow the blood. Pinch the nostrils together with your thumb and index finger for about 10 minutes.
The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?
Are you aware of having any allergies?
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:
Dehydration
While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?
When the patient first noticed the lesion
A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is:
Candidiasis
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?
Black, hairy tongue is a fungal infection caused by all the antibiotics you have received.
During an assessment, a patient mentions that “I just can’t smell like I used to. I can barely smell the roses in my garden. Why is that?” For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply.
Cigarette smoking, chronic allergies and aging.
Functions of the middle ear:
(1) Conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear.
(2) Protects the inner ear by reducing the amplitude of loud sounds.
(3) Its eustachian tube allows equalization of air pressure on each side of the tympanic membrane in order to prevent membrane rupture.
Pathway of hearing:
The normal pathway of hearing is known as air conduction (AC) and is the most efficient. An alternate route of hearing is known as bone conduction (BC); here the bones of the skull vibrate and these vibrations are transmitted directly to the inner ear and to cranial nerve VIII
Hearing loss:
- A conductive hearing loss involves a mechanical dysfunction of the external or middle ear and is considered a partial loss because the person is able to hear if the sound amplitude is increased enough to reach the nerve elements in the inner ear. Common causes are impacted cerumen, foreign bodies in the ear canal, perforated tympanic membrane, and otosclerosis.
- A sensorineural (or perceptive) hearing loss indicates pathology of the inner ear, cranial nerve VIII, or the auditory areas of the brain. A simple increase in amplitude may not enable the person to hear. Common causes are ototoxic drugs and presbycusis, a gradual nerve degeneration that occurs with aging.
- A mixed loss is a combination of both types of hearing loss in the same ear.
Cerumen:
Purpose of cerumen is to protect and lubricate the ear.
Eustachian tube:
Helps equalize are pressure on both sides of the tympanic membrane.
Air conduction:
Normal pathway for hearing.
Ear examination of an 80-year-old patient; which findings would be normal?
High-tone frequency loss
A 17-year-old student is a swimmer on her high school’s swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to:
Use rubbing alcohol or 2% acetic acid teardrops after every swim
“Buzzing sound” in the ear
Tinnitus
Changes in hearing that occur with aging:
Progression of hearing loss is slow, the aging person may find it harder to hear consonants than vowels, sounds may be garbled and difficult to localize.
The anal canal:
Is the outlet for the gastrointestinal tract.
Colonoscopy-
a test that allows the physician to look at the inner lining of the large intestines, with a thin flexible tube
A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He is concerned about cancer. How should the nurse respond? What would you say?
The enlargement of your prostate is caused by hormonal changes, and not cancer
Symptoms may include urinary frequency, urgency, hesitancy, straining to urinate, wear stream, intermittent stream, or sensation of not emptying
A 30-year-old woman is visiting the clinic because of “pain in my bottom when I have a bowel movement.” The nurse should assess for which problem?
Hemorrhoids
After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n):
Colonoscopy every 10 years
What position should a woman be in for a rectal exam
Left lateral decubitus
Pigmentation of anus is darker than the surrounding skin, the anal opening is closed, and a skin sac that is shiny and blue is noted. Pain with bowel movements and occasionally noted some spots of blood-
Thrombosed hemorrhoid
Anal fistula, rectal prolapse, rectal polyp, rectal fissure-
Anal fistula—An abnormal passage from inner anus or rectum out to the skin surrounding the anus. May occur from chronic GI inflammation, local abscess. The tract may drain serosanguineous or purulent drainage.
Rectal prolapse—protrusion of the rectal mucous membrane through the anus
Rectal polyp—protruding growth from the rectal mucous membrane
Rectal fissure—longitudinal tear in the superficial mucosa at the anal margin
Rectal Prolapse-
Moist, red, doughnut shaped protrusion from the anus
A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition?
Prostatitis
During a health history of a patient who complains of chronic constipation, the patient asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be:
Broccoli
During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling “full,” has a distended abdomen, and states that she has not had a bowel movement “for several days.” The nurse suspects which condition?
Fecal impaction
Human Papilloma Virus-
A sexually transmitted disease that may clear on its own but for those that don’t clear it can lead to cervical cancer.
What is the CDC’s recommendation for the HPV vaccine?
Girls or boys starting at age 11 or 12 years old with a series of 3 injections with a 6month period
Is the HPV vaccine recommended for girls/women before they become sexually active? T or F
True
Can the HPV virus linger in a woman’s cervix and cause changes that may lead to cervical cancer? T or F
True
Changes normally associated with menopause occur because the cells in the reproductive tract are:
Aging
Changes associated with menopause:
Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium
Premenstrual Syndrome, Menarche, Menopause, Menstrual Cycle, Dysmenorrhea-
o Premenstrual syndrome-refers to physical and emotional symptoms that occur in the one to two weeks before a woman’s period. Common symptoms include acne, tender breasts, bloating, feeling tired, irritable and mood changes.
o Menarche—onset of first menses, usually occurring between 11 and 13 years of age
o Menopause—cessation of menses, usually occurring around 48 to 51 years of age
o Menstrual cycle- changes that occur naturally in a woman’s body to prepare it for pregnancy. In a normal menstrual cycle, women experience menstruation (also known as a period) followed by the release of an egg. During menstruation blood, cells and mucus are discharged from the uterus.
o Dysmenorrhea- abnormal cramping and pain associated with menstruation
Plan to begin the annual gynecologic examination with:
Menstrual history, generally nonthreatening
During the interview with a female patient, the nurse gathers data that indicate the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion?
I have been noticing that I sweat a lot more than I used to, especially at night.
A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts and wonders if these changes could be attributable to the hormone replacement therapy (HRT) she started 3 months earlier. The nurse should tell her:
HRT has several side effects, including fluid retention, breast tenderness and vaginal bleeding.
During the interview, a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurse’s most appropriate response to this would be:
I’d like some information about the discharge. What color is it?
A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, “Have you noticed any:
Unusual vaginal discharge or itching?
Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview?
Women often have questions about their sexual relationship and how it affects their health. Do you have any questions?
A 22-year-old woman has been considering using oral contraceptives. As a part of her health history, the nurse should ask:
If you smoke, how many cigarettes do you smoke per day?
A nurse is assessing a patient’s risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be:
Do you use a condom with each episode of sexual intercourse?
The nurse is preparing to interview a postmenopausal woman. Which of these statements is true as it applies to obtaining the health history of a postmenopausal woman?
The nurse should ask a postmenopausal woman if she has ever had vaginal bleeding.
During the examination portion of a patient’s visit, she will be in lithotomy position. Which statement reflects some things that the nurse can do to make this position more comfortable for her?
Elevate her head and shoulders to maintain eye contact.
A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are:
Avoid intervenes, inserting anything into the vagina or douching within 24 hours of your appointment.
During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which condition?
Candidiasis
A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. Inguinal lymphadenopathy present is also present. The most likely cause of these lesions is:
Herpes simplex virus type 2
A 25-year-old woman comes to the emergency department with a sudden fever of 38.3° C and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of:
Pelvic inflammatory disease.
A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, “How often do I need to have this Pap test done?” Which reply by the nurse is correct?
“After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years.”
What problems occur as a result of atrophic vaginitis?
Itching, dryness, burning sensation, dyspareunia, mucoid discharge with noticeable blood.
What specific questions would you asks an elderly female patient whose period stopped 5 years ago and has recently restarted?
When did it start, amount, color, taking any medications, history of any cancer in the family, past surgeries, any abdominal pain.
Changes normally associated with menopause occur because the cells in the reproductive tract are aging? T or F
True
When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information, the nurse would consider this as normal findings.
True
Inguinal Hernia-
An inguinal hernia is herniation of bowel (usually small intestine) through a weak area in the lower abdominal wall. The area of the lower abdominal wall is also called the inguinal or groin region.
2 types of inguinal hernias
- indirect inguinal hernias, which are caused by a defect in the abdominal wall that is congenital, or present at birth
- direct inguinal hernias, which usually occur only in male adults and are caused by a weakness in the muscles of the abdominal wall that develops over time
A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. What is the appropriate term for burning and pain during urination?
Dysuria
Stress Incontinence-
Involuntary urine loss with physical strain, sneezing, or coughing due to weakness of pelvis floor.
What specific questions would be most appropriate when obtaining a genitourinary history from an older man?
Frequency, urgency, nocturia, dysuria, hesitancy, straining, color, difficulty controlling your urine, accidentally urinating when you sneeze, laugh, cough or bear down, any history of kidney disease, prostate problems.
When the nurse is performing a genital examination on a male patient, the patient has an erection. The nurse’s most appropriate action or response is to:
Reassure the patient that this is a normal response and continue with the examination.
When performing a genitourinary assessment, the nurse notices that the urethral meatus is ventrally positioned. This finding is:
hypospadias
The nurse is aware of which statement to be true regarding the incidence of testicular cancer?
Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer.
The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate?
“If you notice an enlarged testicle or a painless lump, call your health care provider.”
During an examination of an aging man, the nurse recognizes that normal changes to expect would be:
Decrease in the size of the penis.
When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of:
Genital Warts
A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination the nurse notices an enlarged, red scrotum that is very tender to palpation. Distinguishing the epididymis from the testis is difficult, and the scrotal skin is thick and edematous. This description is consistent with which of these?
Epididymis
The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On examination, the nurse notices a painless round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. These findings are most consistent with a(n) __ hernia.
Direct Inguinal
The nurse is providing patient teaching about an erectile dysfunction drug. One of the drug’s potential side effects is prolonged, painful erection of the penis without sexual stimulation, which is known as:
Priapism
During a physical examination, the nurse finds that a male patient’s foreskin is fixed and tight and will not retract over the glans. The nurse recognizes that this condition is:
Phimosis
A 55-year-old man is in the clinic for a yearly checkup. He is worried because his father died of prostate cancer. The nurse knows which tests should be performed at this time? Select all that apply.
Blood test for prostate-specific antigen (PSA) and digital rectal examination
Activity of Daily Living
Tasks that are necessary for self-care, such as eating/feeding, bathing, grooming, toileting, walking, and transferring.
Advanced Activities of Daily Living
Activities that an older adult performs as a family member or as a member of society or community, including occupational and recreational activities.
Caregiver Assessment
Assessment of the health and well-being of an individual’s caregiver.
Caregiver Burden
The perceived strain by the person who cares for an older, chronically ill, or disabled person.
Domains of Cognition
Domains included in mental status assessments, such as attention, memory, orientation, language, visuospatial skills, and higher cognitive functions.
Environment
Assessment of an indovodual’s home environment and community systems, including hazards at home.
Functional Ability
The ability of a person to perform activities necessary to live in modern society; may include driving, using the telephone, or performing personal tasks such as baking or toileting.
Functional Assessment
A systematic assessment that includes assessment of an individual’s activities of daily living, instrumental activities of daily living, and mobility.
Functional Status
A person’s actual performance of activities and tasks associated with current life roles.
Geriatric Assessment
Multidimensional assessment; physical examination and assessments of mental status, functional status, social and economical status, pain, and physical environment safety.
Home Care
Supportive services provided in the home: skilled nursing care, primary care, therapy (physical, occupational, speech), social work, nutrition, case management, ADL assistance, durable medical equipment.
Instrumental Activities of Daily Living
Functional abilities necessary for independent community living, such as, shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation.
Katz Index of Independence in Activities of Daily Living
An instrument used to measure physical function in older adults and the chronically ill.
Lawton Instrumental Activities of Daily Living
An instrument used to measure an individual’s ability to perform instrumental activities of daily living; may assist in assessing one’s ability to live independently.
Physical Performance Measures
Tests that measure balance, gait, motor coordination, and endurance.
Social Domain
The domain that focuses on an individual’s relationships within family, social groups, and the community.
Social Networks
Informal supports accessed by older adults, such as family members and close friends, neighbors, church societies, neighborhood groups, and senior centers.
Spiritual Assessment
Assessment of the individual’s spiritual health.
An appropriate tool to assess an individual’s instrumental activities of daily living is a tool by:
a. Katz
b. Lawton CORRECT ANSWER
c. Tinetti
d. Norbeck
Which statement is true regarding an individual’s functional status?
a. Functional status refers to one’s ability to care for another person.
b. An older adult’s functional status is usually static over time.
c. An older adult’s functional status may vary from independence to disability. CORRECT ANSWER
d. Dementia is an example of functional status.
An older person is experiencing an acute change in cognition. You recognize that this disorder is?
a. Alzheimer dementia
b. Attention deficit disorder
c. Depression
d. Delirium CORRECT ANSWER
Assessment of the social domain includes:
a. Family relationships CORRECT ANSWER
b. Ability to cook meals
c. Ability to balance the checkbook and pay bills
d. Hazards found in the home
You will use which technique when assessing an older individual who has cognitive impairment?
a. Ask open-ended questions
b. Complete the entire assessment in one session
c. Ask the family members for information instead of the older individual
d. Ask simple questions that have yes or no answers. CORRECT ANSWER
An older person needs to be assessed before going home as to whether he or she is able to go outside alone safely. Which test is best for this assessment?
a. Up and go test CORRECT ANSWER
b. Performance of activities of daily living
c. Older americans resources and services multidimensional functional assessment questionnaire
d. Lawton IADL Instrument
An older adult has had surgery for a fractured hip and has a history of dementia. You should keep in mind that older adults with cognitive impairment:
a. Experience less pain
b. can provide a self-report of pain *CORRECT ANSWER8
c. Cannot be relied on to self-report pain
d. Will not express pain sensations.
An appropriate use of the caregiver strain index would be which situation?
a. A daughter who is taking her older father home to live with her
b. An older patient who lives alone
c. A wife who has cared for her husband for the past 4 years at home CORRECT ANSWER
d. A son whose parents live in an assisted living facility
Which is an example of a formal social support network for the aging adult?
a. A neighbor who drops by with newspapers and magazines on a regular basis
b. An area church that offers a weekly activity an luncheon for seniors in the neighborhood
c. A home health care agency that provides weekly blood pressure screenings at the church luncheon CORRECT ANSWER
d. A senior citizen chess club whose members hold classes at the local boys club
When completing a spiritual assessment you should?
a. Use yes and no questions as the foundation for future dialogue
b. Use open-ended questions to help the patient understand potential coping mechanisms CORRECT ANSWER
c. Try to complete this assessment as soon as possible after meeting the patient
d. Wait until a member of the clergy can be involved in the assessment
When you perform a functional assessment of an older patient, which is most appropriate?
a. Observe the patient’s ability to perform the tasks CORRECT ANSWER
b. Ask the patient’s wife or husband how he or she does when performing tasks
c. Review the medical record for information on the patient’s abilities
d. Ask the pastient’s physician for information on the patient’s ability
The Lawton IADL instrument is described by which of the following?
a. The nurse uses direct observation to implement this tool
b. It is designed as a self-report measure of performance rather than ability CORRECT ANSWER
c. It is not useful in the acute hospital setting
d. It is best used for those residing in an institutional setting
An older adult’s advanced activities of daily living would include:
a. Recreational activities CORRECT ANSWER
b. Meal Preparation
c. Balancing the checkbook
d. Self-grooming activities
When using the various instruments to assess an older person’s activities of daily living, remember that a disadvantage of these instruments includes:
a. The reliability of the tools
b. Self or proxy report of functional activities CORRECT ANSWER
c. Lack of confidentiality during the assessment
d. Insufficient detail about the deficiencies identified
Acculturation
Process of social and psychological exchanges with encounters between persons of different cultures, resulting in changes in either group.
Cultural and Linguistic Competence
A set of congruent behaviors, attitudes and policies that come together in a system among professionals that enables work in cross-cultural situations.
Culture
The nonphysical attributes of a person-the thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups.
Cultural Care
Professional health care that is culturally sensitive, appropriate, and competent.
Ethnicity
A social group within the social system that claims to possess variable traits such as common geographic origin, migratory status, and religion.
Ethnocentrism
Tendency to view your own life as the most desirable, acceptable, or best and to act superior to another culture’s way of life.
Folk Healer
Lay healer in the person’s culture apart from the biomedical or scientific health care system
Health or Illness
the balance or imbalance of the person, both within one’s being (physical, mental, and/or spiritual) and in the outside world (natural, communal, and/or metaphysical)
Religion
The belief in a divine subhuman power or powers to be obeyed and worshiped as the creator and ruler of the universe and a system of beliefs, practices, and ethical values
Socialization
The process of being raised within a culture and acquiring the characteristics of that group
Spirituality
A person’s personal effort to find purpose and meaning in life
Title VI of the Civil Rights Act of 1964
A federal law that mandates that when people with limited English proficiency (LEP) seek health care settings such as hospitals, nursing homes, clinics, daycare centers, and mental health centers, services cannot be denied to them
Values
A desirable or undesirable state of affairs and a universal feature of all cultures
Which statement best describes religion?
a. an organized system of beliefs concerning the cause, nature, and purpose of the universe CORRECT ANSWER
b. Belief in a divine or superhuman to be obeyed and worshiped
c. Affiliation with one of the 1200 recognized religions in the United states
d. The following of established rituals, especially in conjunction with health seeking behaviors
The major factor contributing to the need for cultural care nursing is?
a. an increasing birth rate
b. limited access to health care services
c. demographic change CORRECT ANSWER
d. a decreasing rate of immigration
The term culturally competent implies that the nurse:
a. is prepared in nursing
b. possesses knowledge of the traditions of diverse peoples
c. applies underlying knowledge to providing nursing care
d. understands the cultural context of the patient’s situation CORRECT ANSWER
You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication?
a. maintaining a professional respectful demeanor
b. allowing for additional time to complete the process
c. providing the patient with a paper and pencil so he or she can write down the questions that you are going to ask CORRECT ANSWER
d. seeing if there are any family members present who may assist with the interview process
Which culture would describe illness as hot and cold imbalance?
a. Asian-American heritage
b. African-American heritage
c. Hispanic-American heritage CORRECT ANSWER
d. American Indian heritage
Of what does the patient believe the amulet is protective?
a. the evil eye CORRECT ANSWER
b. being kidnapped
c. exposure to bacterial infections
d. an unexpected fall
Which statement best illustrates the difference between religion and spirituality?
a. religion reflects an individual’s reaction to life events whereas spirituality is based on whether the individual attends religious services
b. religion is characterized by identification of a higher being shaping one’s destiny while spirituality reflects the individual’s perception of one’s life having worth or meaning CORRECT ANSWER
c. Religion is the expression of spiritual awakening whereas spirituality is based on belief in divine right
d. religion is the active interpretation of one’s spirituality
The first step to cultural competency by a nurse is to:
understand your own heritage and its basis in cultural values
Which statement is true in regard to pain?
The cultural background of the patient is important in a nurses’s assessment of that patient’s pain.
Which factor is identified as a priority influence on a patient’s health status?
Poverty
Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?
What cultural or spiritual beliefs are important to you.
Which statement best describes ethnocentrism?
The tendency to view your own way of life as the most desirable.
Which category is appropriate in a cultural assessment?
Health-related beliefs
Which health belief practice is associated with patients who are of American Indian heritage?
Eating compatible foods in one’s diet.
Which statement best reflects the Magicoreligious causation of illness?
Belief in the struggle between good and evil is reflected in the regulation of health and illness.
Auscultatory gap
A brief period when Korotkoff sounds disappear during auscultation of blood pressure; common with hypertension.
Bradycardia
Heart rate fewer than 50 or 60 beats per minute in the adult (depending on agency).
Sphygmomanometer
Instrument for measuring arterial blood pressure.
Stroke Volume
Amount of blood pumped out of the heart with each heartbeat.
Trachycardia
Heart rate greater than 95 beats per minute in the adult.
The 4 areas to consider during the general survey include:
Physical appearance, body structure, mobility, and behavior.
You are assessing a patient’s gait. What do you expect to find?
Gait is as wide as the shoulder width.
An 18-month old child is brought into the clinic for a health screening visit. To assess the height of the child:
Use a horizontal measuring board.
Which changes in head circumference measurements in relation to chest measurements will occur from infancy through early childhood?
The newborn’s head will be 2 cm larger than the chest circumference, but between 6 months and 2 years, they will be about the same.
Which changes regarding height and weight occur during the 80’s and 90’s?
Both decrease.
During an initial home visit, the patient’s temperature is noted to be 97.4 degrees F. How would you interpret this?
It cannot be evaluated without knowledge of the person’s age.
Select the best description of an accurate assessment of a patient’s pulse:
Begin counting with zero; count for 30 seconds.
After assessing the patient’s pulse, the practitioner determines it to be normal. This would be recorded:
2+
Select the best description of an accurate assessment of a patient’s respiration:
Count for 30 seconds after pulse assessment.
Pulse pressure is described as?
The difference between the systolic and diastolic pressure.
The examiner suspects a patient has coarctation of the aorta. Which assessment finding supports this suspicion?
The pressure is lower than in the arm.
Mean arterial pressure is:
Diastolic pressure plus one third of the pulse pressure.
Why is it important to match the appropriate size of blood pressure cuff to the person’s arm and shape and not to the person’s age?
Using a cuff that is too narrow will give a false reading.
A patient is being seen in the clinic for complaints of fainting episodes that started last week. How should you proceed with the examination?
Record the blood pressure in the lying, sitting, and standing positions.
The nurse is conduction a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?
An increased respiratory rate and a shallower inspiratory phase are possible findings.
Android Obesity
Excess body fat that is placed predominantly within the abdomen and upper body, as opposed to the hips and thighs.
Anthropometry
Measurement of the body (height, weight, circumferences, skin fold thickness).
Body Mass Index BMI
Weight in kilograms divided by height in meters squared; value of 30 or more is indicative of obesity; value less that 18.5 is indicative of under nutrition.
Diet History
A detailed record if dietary intake obtainable from 24 hour recalls, food frequency questionnaires, food diaries, and similar sources.
Kwashiorkor
Primarily a protein deficiency characterized by edema, growth failure, and muscle wasting.
Malnutrition
May mean any nutrition disorder but usually refers to long term nutritional inadequacies or excesses.
Marasmic Kwashiorkor
Combination of chronic energy deficit and chronic or acute protein deficiency.
Marasmus
Results from energy and protein deficiency, manifesting with significant loss of body weight, skeletal muscle, and adipose tissue mass, but with serum protein concentrations relatively intact.
Nutritional Monitoring
Assessment of dietary or nutritional status at intermittent times with the aim of detecting changes in the dietary or nutritional status of a population.
Nutrition Screening
a process used to identify individuals at nutritional risk or with nutritional problems.
Obesity
Excessive accumulation of body fat; usually defined as 20% above desirable weight or body mass index of 30.0-39.9
Protein Calorie Malnutrition (PCM)
Inadequate consumption of protein and energy, resulting in gradual body wasting and increased susceptibility to infection.
Recommended Dietary Allowance (RDA)
Levels of intake of essential nutrients considered to be adequate to meet the nutritional needs of almost all healthy persons.
Sarcopenic Obesity
Combined loss of muscle mass with weight gain occurring in old age.
Skinfold Thickness
Double fold of skin and underlying subcutaneoustissue that is measured with skinfold calipers at various body sites.
Waist-to-hip Ratio (WHR)
Waist or abdominal circumference divided by the hip or gluteal circumference; method for assessing fat distribution.
The balance between nutrition intake and nutrient requirements is described as:
Nutritional Status
You are providing health promotion teaching for a newly pregnant woman, and recommend which of the following weight gain parameters for a healthy pregnancy?
The recommendation depends on the BMI of the mother at the start of the pregnancy.
Which is a normal expected change with aging?
Decrease in height.
You obtain which data when screening patients for nutritional status?
Weight and nutrition intake history.
A 24-hour recall of dietary intake is used:
As a questionnaire or interview of everything eaten within the last 24 hours.
Mary, a 15 year old, has come for a school physical. During the interview, you learn that menarche has not occurred. The BMI is 17.1. You suspect:
Nutritional deficiency
Which older adult is at lowest risk for alteration in nutritional status?
65 year old widower who visits a senior center with a meal program 5 days per week.
The examiner is completing an initial assessment for a patient admitted to a long-term care facility. The patient is unable to stand for a measurement of height. To obtain this important anthropometric information, the examiner would?
Measure arm span.
Which assessment finding indicates a patient at nutrition risk?
BMI = 19kg/m(2)
Marasmus is often characterized by:
Low weight for height
Which BMI category in adults is indicative of obesity?
30.0-39.9 kg/m(2)
Why should you ask about the use of medications when assessing a patient’s nutritional status?
Many drugs can interact with nutrients and impair their digestion, absorption, metabolism, or uptake.
Alopecia
Baldness; Hair loss.
Annular
Circular shape to skin lesion
Bulla
Elevated cavity containing free fluid larger than 1cm in diameter.
Confluent
Skin lesions that run together.
Crust
Thick, dried-out exudate left on skin when vesicles or pustules burst or dry up.
Cyanosis
Dusky blue color to skin or mucous membranes as a result of increased amount of non oxygenated hemoglobin.
Erosion
Scooped-out shallow depressions of skin.
Erythema
Intense redness of the skin due to excess blood in dilated superficial capillaries, as in fever or inflammation.
Excoriation
Self-inflicted abrasion on skin due to scratching.
Fissure
Linear crack in skin extending into the dermis.
Furuncle
Boil; suppurative inflammatory skin lesion due to infected hair follicle.
Hemangioma
Skin lesion due to benign proliferation of blood vessels in the dermis.
Iris
Target shape of skin lesion.
Jaundice
Yellow color to skin, palate, and sclera due to excess bilirubin in the blood.
Keloid
Hypertrophic scar, elevated beyond site of the original injury.
Lichenification
Tightly packed set of papules that thickens skin; caused by prolonged intense scratching.
Lipoma
Benign fatty tumor.
Maceration
Softening of the tissue by soaking.
Macule
Flat skin lesion with only a color change.
Nevus
Mole; circumscribed skin lesion due to excess melanocytes.
Pallor
Excessively pale, whitish pink color to lightly pigmented skin.
Papule
Palpable skin lesion smaller than 1cm in diameter.
Plaque
Skin lesion in which papules coalesce or come together.
Pruritus
Itching.
Purpura
Red-purple skin lesion due to blood in tissues from breaks in blood vessels.
Pustule
Elevated cavity containing thick, turbid fluid.
Scale
Compact desiccated flakes of skin from shedding of dead skin cells.
Telangiectasia
Skin lesion due to permanently enlarged and dilated blood vessels that are visible.
Ulcer
Sloughing of necrotic inflammatory tissue that causes a deep depression in skin, extending into dermis.
Vesicle
Elevated cavity containing free fluid up to 1cm in diameter.
Wheal
Raised red skin lesion due to interstitial fluid.
Zosteriform
Linear shape of skin lesion along a nerve route.
Select the best description of the secretion of the eccrine glands.
Dilute saline solution
To assess for early jaundice, you will assess?
Sclera and hard palate.
Checking for skin temperature is best accomplished by using?
Dorsal surface of hand
Assessing a patient’s skin turgor is done to assess which clinical finding?
Dehydration
You note a lesion during a skin assessment. Which is the best way to document this finding?
Dark brown raised lesion, with irregular border, on dorsum of right foot, 3cm in size, with no drainage.
You examine the nail beds of a patient. Which finding indicates a normal angle?
160 degrees
You are assessing capillary refill. The room is warm. Which finding would be considered normal?
< 1 second.
During a routine visit, M.B, age 78 asks about a small, round, flat, brown macules on the hands. What is your best response after assessing the areas?
These are the result of sun exposure and do not require treatment.
An area of thin shiny skin with decreased visibility of normal skin markings is most likely:
Atrophy
Flattening of the angle between the nail and bed is:
Described as clubbing
A configuration of individual lesions arranged in circles or arcs, as occurs with ringworm, is described as a:
Annular lesion
The “A” in the ABCDE rule for skin cancer stands for:
Asymmetry
A risk factor for melanoma is?
Skin that freckles or burns before tanning
Herpes zoster infection (shingles) is characterized by:
Lesion only on one side of the body; does not cross the midline.
Basel cell layer
Epidermis
Aids protection by cushioning
Subcutaneous layer
Collagen
Dermis
Adipose tissue
Subcutaneous tissue
Uniformly thin
Epidermis
Stratum corneum
Epidermis
Elastic tissue
Dermis
Absence of red-pink tones from the oxygenated hemoglobin in blood?
Pallor
Intense redness of the skin due to excess blood in the dilated superficial capillaries:
Erythema
Bluish mottled color that signifies decreased perfusion:
Cyanosis
Increase in bilirubin in the blood causing a yellow color in the skin:
Jaundice
Tiny, punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks?
Erythema toxicum
Lower half of body turns red, upper half blanches?
Harlequin
Transient mottling on trunk and extremities?
Cutis marmorata
Bluish color around the lips, hands, fingernails, feet, and toenails?
Acrocyanosis
Large round or oval patch of light brown usually presented at birth?
Cafe au lait spot
Yellowing of skin, sclera, and mucous membranes due to increased numbers of red blood cells hemolyzed after birth?
Physiologic jaundice
Yellow-orange color in light skinned persons from large amounts of foods containing carotene?
Carotenemia
Abduction
Moving a body part away from an axis or the midline
Adduction
Moving a body part toward the center or toward the midline
Ankylosis
Immobility, consolidation, and fixation of a joint because of disease, injury, or surgery; most often due to chronic rheumatoid arthritis
Ataxia
Inability to perform coordinated movements
Bursa
Enclosed sac filled with viscous fluid located in joint areas of potential friction
Circumduction
Moving the arm in a circle around the shoulder.
Crepitation
Dry crackling sound or sensation due to grating of the ends of damaged bone.
Dorsal
Directed toward or located on the surface
Dupuytren contracture
Flexion contracture of the fingers due to chronic hyperplasia of the palmar fascia
Eversion
Moving the sole of the foot outward at the ankle
Extension
Straightening a limb at a joint
Flexion
Bending a limb at the joint
Ganglion
Round, cystic, nontender nodule overlying a tendon sheath or joint capsule, usually on dorsum of wrist
Hallux valgus
Lateral or outward deviation of the great toe
Inversion
Moving of the sole of the foot inward at the ankle
Kyphosis
Outward or convex curvature of the thoracic spine; hunchback
Ligament
Fibrous band running directly from one bone to another bone that strengthens the joint
Lordosis
Inward or concave curvature of the lumbar spine
Nucleus pulposus
Center of the intervertebral disc
Olecranon process
Bony projection of the ulna at the elbow
Patella
Kneecap
Plantar
Refers to the surface of the sole of the foot
Pronation
Turning the forearm so that the palm side is down
Protraction
Moving a body part forward and parallel to the ground
Range of motion (ROM)
Extent of movement of a joint
Retraction
Moving a body part backward and parallel to the ground
Rheumatoid arthritis
Chronic systemic inflammatory disease of the joints and surrounding connective tissue
Sciatics
Nerve pain along the course of the sciatic nerve that travels down from the back or thigh through the leg and into the foot
Scoliosis
S-shaped curvature of the thoracic spine
Supination
Turning the forearm so that the palm is up
Talipes equinovarus
Congenital deformity of the foot in which it is planter flexed and inverted (clubfoot)
Tendon
Strong fibrous cord that attaches a skeletal muscle to a bone
Torticollis
Wryneck; contraction of the cervical neck muscles, producing torsion of the neck
During the assessment of the spine, the patient would be asked to?
Flex, extend, abduct, and rotate
Pronation and supination of the hand and forearm are the result of the articulation of the?
Radius and ulna
Anterior and posterior stability are provided to the knee joint by the?
Anterior and posterior cruciate ligaments
A 70 year old woman has come for a health examination. Which of the following is a common age related change in the curvature of the spinal column?
Kyphosis
Examination of the shoulder includes 4 motions, they are?
Forward flexion, internal rotation, abduction, and external rotation.
The bulge sign is a test for?
Swelling in the suprapatellar pouch
The examiner measures a patient’s legs for length discrepancy, which is a normal finding?
Within 1cm of each other
A 2 year old child comes in the clinic for a health examination. A common finding for this age group is?
Lordosis
A positive Phalen test and Tinel sign are found in a patient with?
Carpel Tunnel Syndrome
When assessing an infant, the examiner completes the Ortolani maneuver by?
Gently lifting and abducting the infant’s flexed knees while palpating the greater trochanter with the fingers
Hematopoiesis takes place in which of the following?
Bone marrow
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are know as?
Ligaments
Bending a limb at a joint
Flexion
Straightening a limb or joint
Extension
Moving a limb away from the midline of the body
Abduction
Moving a limb toward the midline of the body
Adduction
Turning the forearm so that the palm is down
Pronation
Turning the forearm so that the palm is up
Supination
Moving the arm in a circle around the shoulder
Circumduction
Moving the sole of the foot inward at the ankle
Inversion
Moving the sole of the foot outward at the ankle
Eversion
Moving the head around a central axis
Rotation
Moving a body part forward and parallel to the ground
Protraction
Moving a body part backward and parallel to the ground
Retraction
Raising a body part
Elevation
Lowering a body part
Depression
Alveoli
Functional units of the lung; the thin walled chambers surrounded by networks of capillaries that are the site of respiratory exchange of carbon dioxide and oxygen
Angle of Louis
Manubriosternal angle, the articulation of the manubrium of the body of the sternum, continuous with the second rib
Apnea
Cessation of breathing
Asthma
An abnormal respiratory condition associated with allergic hypersensitivity to certain inhaled allergens, characterized by inflammation, bronchospasm, wheezing and dyspnea
Atelectasis
An abnormal respiratory condition characterized by collapsed, shrunken, deflated sections of the alveoli
Bradypnea
Slow breathing, fewer than 10 breaths per minute, regular rate
Bronchiole
One of the smaller respiratory passageways into which the segmental bronchi divide
health assessment 1 final exam
rasmussen university health assessment final exam
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