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Assessment Test #1
Vocab for test 1 (2/12/2013)
160
Nursing
Undergraduate 2
02/11/2013

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Term
NURSING ASSESSMENT
Definition
Collection of data about an individual's health state.
Term
DATA BASE
Definition
Subjective data, objective data, patient record and lab results.
Term
NURSING PROCESS
Definition
Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation (ADPIE)
Term
COMPLETE DATA BASE (TOTAL HEALTH HISTORY)
Definition
Health state, cultural beliefs, values, family, social, health behaviors.
Term
PHI
Definition
Protected Health Information (name, photo, DOB, SSN, admission date, address, phone #, health info)
Term
PQRSTU + L
Definition
Provocative/palliative
Quality/quantity
Region/radiation
Severity
Timing
Understanding (perception)
Location
Term
ASSESSMENT TECHNIQUES (4)
Definition
Inspection, Palpation, Percussion, Auscultation
Term
INSPECTION
Definition
Careful observation of body as a whole, then each body area
Term
PALPATION
Definition
Light: 1-2cm - surface tenderness; superficial masses; temperature.
Deep: > 2cm - Condition of organs; masses; tenderness.
PALPATE TENDER AREAS LAST.
Term
PERCUSSION
Definition
Strike body to emit sounds or determine tenderness
Term
PERCUSSION TONES - TYMPANY
Definition
Abdomen (stomach) - Hollow
Term
PERCUSSION TONES - HYPERRESONANCE
Definition
Too much air in the lung
Term
PERCUSSION TONES - RESONANCE
Definition
Air filled lungs
Term
PERCUSSION TONES - DULLNESS
Definition
solid filled muscle, fluid filled organ
Term
PERCUSSION TONES - FLATNESS
Definition
Bone
Term
AUSCULTATION
Definition
Listening to sounds from body (cardiac & respiratory)
Term
USE OF STETHOSCOPE
Definition
Diaphragm - high pitched sounds (breath)
Bell - low pitched sounds (heart murmurs)
Term
ABCDEs: ASSESSMENT FOR MELANOMAS
Definition
Asymmetry
Border
Color
Diameter
Elevation/Expansion
Term
PALLOR
Definition
Whiteness, paleness
Term
ERYTHEMA (air-uh-theme-uh)
Definition
redness
Term
CYANOSIS
Definition
bluish color
Term
JAUNDICE
Definition
Yellow color (bilirubin --> Liver)
Term
VITILIGO
Definition
Patchy areas of decreased pigmentation (Michael Jackson)
Term
EDEMA
Definition
Swelling - look for indentation (pitting edema)
Term
TURGOR
Definition
Resiliency, elasticity, recoil
Term
CLUBBING
Definition
Ends of fingers abnormally large (bulb-like). Nails smooth and shiny
Term
BEAU'S LINES
Definition
Growth of nail bed damaged or stopped (HORIZONTAL LINES)
Term
THYROID PROBLEMS & HAIR
Definition
Hypothyroidism: dry, brittle
Hyperthyroidism: abn. soft, silky
Term
PRIMARY LESION - MACULE
Definition
< 1 cm, flat. Example: freckles, flat moles
Term
PRIMARY LESION - PATCH
Definition
> 1cm, flat
Term
PRIMARY LESION - PAPULE
Definition
< 1cm, elevated. Example: wart, elevated mole
Term
PRIMARY LESION - PLAQUE
Definition
> 1 cm, elevated
Term
PRIMARY LESION - VESICLE (BLISTER)
Definition
< 1 cm, clear fluid
Term
PRIMARY LESION - BULLA
Definition
> 1 cm, clear fluid
Term
PRIMARY LESION - PUSTULE
Definition
Varying size, purulent fluid
Term
PRIMARY LESION - WHEAL/URTICARIA
Definition
Hive/ multiple hives (allergic reaction or mosquito bite)
Term
SECONDARY LESION
Definition
Results from changes over time or from an existing lesion
Term
SECONDARY LESION - CRUST
Definition
Scab
Term
SECONDARY LESION - SCALE
Definition
Dry skin
Term
SECONDARY LESION - FISSURE
Definition
Crack (Athlete's foot)
Term
SECONDARY LESION - EROSION
Definition
Shallow depression, no bleeding, heals without scar (does not extend into dermis)
Term
SECONDARY LESION - ULCER
Definition
Deeper depression extending into dermis
Term
SECONDARY LESION - EXCORIATION
Definition
Abrasion; superficial; sometimes crusted; scratches from intense itching
Term
SECONDARY LESION - SCAR
Definition
A permanent fibrotic change
Term
SECONDARY LESION - ATROPHIC SCAR
Definition
Skin level depressed with loss of tissue
Term
SECONDARY LESION - KELOID
Definition
A hypertrophic scar
Term
SECONDARY LESION - LICHENIFICATION
Definition
Intense scratching, eventually thickens the skin
Term
Skin turgor is assessed to determine:
A. Aging Skin
B. Edema
C. Circulation
D. Dehydration
Definition
D
Term
Skin temperature is assessed by using:
A. Ventral surface of hands
B. Dorsal surface of hands
C. Fingertips
D. Palmar surface of hands
Definition
B
Term
A client's capillary refill is 5 seconds. What should the nurse do?
A. Call the MD
B. Perform a more in depth assessment of circulation
C. Attempt to warm the client's hands
D. Check for edema
Definition
B
Term
What is the correct part of the hand used to assess for vibrations?
A. Fingertips
B. Dorsal surface
C. Ulnar/Palmar surface
D. Radial surface
Definition
C
Term
ATROPHY
Definition
Decrease in size or wasting away of a body part or tissue
Term
CIRCUMSCRIBED
Definition
Confined to a limited area
Term
CONFIGURATION
Definition
Arrangement of lesions
Term
CONTUSION
Definition
Bruise
Term
DIAPHORESIS
Definition
Abnormal sweating/perspiration
Term
ECCHYMOSIS
Definition
Bruise
Term
HEMATOMA
Definition
Goose egg
Term
LESION
Definition
Abnormal change in structure of an organ due to injury or disease. Anything that interrupts pigmentation
Term
NEVUS
Definition
Mole
Term
PETECHIAE
Definition
Minute hemorrhagic spots, pinpoint to pinhead size. Not blanched by pressure (occur during labor or excessive vomiting)
Term
PHOTOSENSITIVITY
Definition
Abnormal sensitivity to light, especially of the eyes
Term
PRURITUS
Definition
Itching
Term
STRIAE
Definition
Stretch mark
Term
REFRACTION
Definition
Bending of light
Term
ACCOMMODATION
Definition
Change for near/far vision. Lens curves differently
Term
CONSTRICTION OF PUPIL
Definition
Bright light and near
Term
DILATION OF PUPIL
Definition
Dark room and far
Term
CONVERGENCE
Definition
Movement of eye inwards
Term
CATARACTS
Definition
Clouding of lens
Term
GLAUCOMA
Definition
Optic nerve pinched, peripheral vision affected
Term
CRANIAL NERVE 2
Definition
Optic
Term
ASSESSING DISTANCE VISION
Definition
Snellen chart - 20/20 = normal
Term
MYOPIA
Definition
Nearsightedness; can't see far away
Term
PRESBYOPIA
Definition
Decrease in vision because of aging process
Term
HYPEROPIA
Definition
Farsightedness; Can't see close up
Term
ASTIGMATISM
Definition
Irregularity of the cornea
Term
CONFRONTATION TEST
Definition
Rough estimate for peripheral vision
Term
EXTRA-OCULAR MOVEMENT
Definition
CN 3, 4, 6.
3 tests:
Cardinal positions of gaze
Cover-Uncover
Corneal Light Reflex
Term
NYSTAGMUS
Definition
Jerking movement of the eyes
Term
CORNEAL LIGHT REFLEX
Definition
@ least 12 inches away. Want light to be in the same spot
Term
STRABISMUS
Definition
Disparity of eye axis
Term
COVER-UNCOVER
Definition
Gaze should not shift
Term
PALPEBRAL FISSURE
Definition
Space between eyelids
Term
BULBAR CONJUNCTIVAE
Definition
Clear, over sclera, with few injections
Term
PALPEBRAL CONJUNCTIVAE
Definition
Inside lids; clear, pink underlying tissue with few injections
Term
CORNEAL REFLEX (CN 5 & 7)
Definition
Blink - CNs intact
Term
EXOPHTHALMOS
Definition
Bulging of the eye
Term
PTOSIS (silent P)
Definition
Drooping eyelid
Term
ECTROPION
Definition
Eyelid turns outward (aging)
Term
ENTROPION
Definition
Eyelid turns inward (eyelashes scratch eye)
Term
PERRLA
Definition
Pupils Equal
Round
React to Light
Accommodation
Term
ANISOCORIA
Definition
Unequal pupil size
Term
MIOSIS
Definition
Contraction of pupil (light room, sunlight)
Term
MYDRIASIS
Definition
Dilation of pupil. Dark room
Term
RED REFLEX
Definition
Want to see red-possessed glow
Term
PAPILLEDEMA
Definition
Too much pressure on/in the eye
Term
OTOTOXIC
Definition
Some medicine affects inner ear (hearing and balance). Not reversible
Term
TINNITUS
Definition
Ringing sensation in one or both ears
Term
CERUMEN
Definition
Ear wax
Term
OTORRHEA
Definition
Discharge from the ear
Term
CONE OF LIGHT (POSITION)
Definition
R - 5 o'clock
L - 7 o'clock
Term
OTITIS MEDIA
Definition
Middle ear infection
Term
PRESBYCUSIS
Definition
Hearing loss due to aging
Term
CONDUCTIVE HEARING LOSS
Definition
External or middle ear disorders that prevent transmission of sound
Term
SENSORINEURAL HEARING LOSS
Definition
Disorders of the inner ear; 8th CN or brain
Term
To assess for early jaundice, the nurse should assess which of the following?
A. Sclera and hard palate
B. Nailbeds
C. Lips
D. All visible skin surfaces
Definition
A. (D later on)
Term
A client has multiple red injections over the sclera. Which structure is most likely involved?
A. Palpebral conjunctiva
B. Bulbar conjunctiva
C. Sclera
D. Iris
Definition
B
Term
Sensorineural hearing loss may be related to:
A. Gradual nerve degeneration
B. Foreign bodies
C. Impacted cerumen
D. Perforated tympanic membrane
Definition
A
Term
Which of the following client's would you be most concerned about?
A. A client with floaters
B. A client with sudden epiphora
C. A client with a sudden onset of visual changes
D. A client with photophobia
Definition
C
Term
EPIPHORA
Definition
Excessive watering of the eyes
Term
PHOTOPHOBIA
Definition
Increased sensitivity to light
Term
The nurse is testing a patient's visual accommodation, which refers to:
A. Pupillary constriction when looking at a near object
B. Pupillary dilation when looking at a far object
C. Changes in peripheral vision in response to light
D. Involuntary blinking in the presence of a bright light
Definition
A
Term
CANTHUS
Definition
Meeting of the upper and lower eyelids (corner)
Term
DIPLOPIA
Definition
Double vision
Term
LIMBUS
Definition
Border of cornea and sclera
Term
SCOTOMATA/SCOTOMA
Definition
Additional blind spot (middle of vision)
Term
OTALGIA
Definition
Pain in the ear
Term
VERTIGO
Definition
No balance; dizzy
Term
NORMOCEPHALIC
Definition
Normal head (~58 cm)
Term
PEDICULOSIS
Definition
Lice - crawl around
Nits - attach to hair shaft

Fast, but do not jump.
Children don't need to be excluded from school
Term
CRANIAL NERVE 5
Definition
Muscle strength & sensation
Term
CRANIAL NERVE 7
Definition
Facial Expressions
Term
[image]
Definition
  • I-     Olfactory
  • II-    Optic
  • III-   Oculomotor
  • IV-   Trochlear
  • V-    Trigeminal
  • VI-    Abducens
  • VII-   Facial
  • VIII-  Acoustic (Vestibulocochlear)
  • IX-   Glossopharyngeal
  • X-    Vagus
  • XI-   Spinal Accessory
  • XII-  Hypoglossal
Term
NASOLABIAL FOLD
Definition
Fold of nose to the fold of mouth (laugh lines)
Term
CRANIAL NERVE 11
Definition
SCM/Trapezius
Term
GOITER
Definition
Enlarged thyroid
Term
NEOPLASM
Definition
Growth
Term
GINGIVA
Definition
Gums
Term
CRANIAL NERVE 12
Definition
Stick out tongue (hypoglossal)
Term
TONSILLAR RATING SYSTEM
Definition
0 - Not visible
+1 - Just visible
+2 - Visible & slightly larger
+3 - Large, visible, extending beyond arches
+4 - Same as above, plus the tonsils may be touching
Term
ALOPECIA
Definition
Loss of hair
Term
CARIES
Definition
Progressive destruction of any kind (teeth). Poor oral hygiene, baby bottle tooth decay
Term
CREPITUS
Definition
Crackling/popping sounds and sensations experienced under the skin and joints
Term
DYSPHAGIA
Definition
Difficulty swallowing
Term
EPISTAXIS
Definition
Bloody nose (Dryness, HTN, decreased vitamin K, trauma)
Term
EXUDATE
Definition
Fluid that leaks out of blood vessels to nearby tissues
Term
GINGIVITIS
Definition
Inflammation of the gums
Term
HALITOSIS
Definition
Bad breath
Term
HIRSUTE
Definition
Covered with hair
Term
LYMPHADENOPATHY
Definition
Disease of the lymph nodes
Term
NARIS/NARES
Definition
Anterior and posterior openings on either side of the nasal cavity (nostril)
Term
PAPILLAE
Definition
Nipple-like structure - taste bud
Term
PATENCY
Definition
State of being open, expanded or unblocked
Term
PHONATION
Definition
Utterance of sounds through the use of vocal cords
Term
PURULENT
Definition
Containing, discharging or causing the production of pus
Term
RHINORRHEA
Definition
Runny nose
Term
SEPTAL DEVIATION
Definition
Displaced nasal septum
Term
SINUSITIS
Definition
Inflammation of the sinuses. Occurs with infection from virus, bacteria or fungus
Term
XEROSTOMIA
Definition
Dry mouth
Term
LYMPH NODES - PREAURICULAR
Definition
In front of the ear
Term
LYMPH NODES - POSTERIOR AURICULAR (MASTOID)
Definition
Superficial to the mastoid process
Term
LYMPH NODES - OCCIPITAL
Definition
At the base of the skull
Term
LYMPH NODES - SUBMENTAL
Definition
Midline, behind the tip of the mandible
Term
LYMPH NODES - SUBMANDIBULAR
Definition
Halfway between the angle and the tip of the mandible
Term
LYMPH NODES - TONSILLAR (JUGULODIGASTRIC)
Definition
Under the angle of the mandible
Term
LYMPH NODES - SUPERFICIAL CERVICAL
Definition
Overlying the sternomastoid muscle
Term
LYMPH NODES - DEEP CERVICAL
Definition
Deep under the sternomastoid muscle
Term
LYMPH NODES - POSTERIOR CERVICAL
Definition
In the posterior triangle along the edge of the trapezius muscle
Term
LYMPH NODES - SUPRACLAVICULAR
Definition
Just above and behind the clavicle, at the sternomastoid muscle
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