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Health Assessment
Exam 2
116
Nursing
10/27/2012

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Cards

Term
These muscles rotate and flex the head.
Definition
sternomastoid muscles
Term
These muscles extend the head and move the shoulders.
Definition
trapezius muscles
Term
The eleventh cranial nerve (XI) is responsible for...
Definition
...muscle movement that permits shrugging of the shoulders by the trapezius muscles and turning the head against resistance by the sternomastoid muscles.
Term
The largest endocrine gland in the body is the...
Definition
thyroid gland.
Term
What is lymph?
Definition
A clear substance composed mostly of excess tissue fluid.
Term
What do lymph nodes do?
Definition
Filter lymph, after the lymphatic vessels collect it but before it returns to the vascular system.
Term
What do lymph nodes filter for?
Definition
The filtering action of lymph nodes removes bacteria and tumor cells from lymph.
Term
___________ and __________ are produced in the lymph nodes as a defense against invasion by foreign substances.
Definition
lymphocytes and antibodies
Term
Normally lymph nodes are either not palpable or they may feel like very small beads. If the nodes are swollen and painful, what could this mean?
Definition
If the nodes become overwhelmed by microorganisms, as happens with an infection such as mononucleosis, they swell and become painful.
Term
What might nodes that are enlarged but not painful mean?
Definition
If cancer metastasizes to the lymph nodes, they may enlarge but not be painful.
Term
Hyperthyroidism is...
Definition
...an increase in thyroid hormone production.
Term
Hyperthyroidism can result in...
Definition
...insomnia, thinning hair, palpitations, and weight loss.
Term
Hypothyroidism is...
Definition
...a decrease in thyroid hormone production.
Term
Hypothyroidism can result in...
Definition
...insomnia, thickening skin and nails, decreased energy levels, and constipation.
Term
Headaches: Character: What are the symptoms that may be present with a tension headache?
Definition
Symptoms of anxiety, tension, and depression may be present.
Term
Headaches: Character: may be accompanied by tearing, eyelid drooping, reddened eye, or runny nose
Definition
cluster headache
Term
Headaches: Character: Neurologic and mental symptoms and nausea and vomiting may develop.
Definition
tumor related headache
Term
Headaches: Character: accompanied by nausea, vomiting, and sensitivity to noise or light
Definition
migraine
Term
Headaches: Onset and Precipitating Factors: No prodromal stage. May be aggrevated by coughing, sneezing, or sudden movement of the head.
Definition
tumor related headache
Term
Headaches: Onset and Precipitating Factors: May have prodromal stage (visual disturbances, vertigo, tinnitus, numbness or tingling of fingers or toes). Precipitated by emotional disturbances, anxiety, or ingestion of alcohol, cheese, chocolate, or other foods and substances to which client is sensitive.
Definition
migraine
Term
Headaches: Onset and Precipitating Factors: may be precipitated by ingesting alcohol
Definition
cluster headache
Term
Headaches: Onset and Precipitating Factors: No prodromal stage. May occur with stress, anxiety, or depression.
Definition
tension headache
Term
Headaches: Location: located around eyes, temples, cheeks, or forehead
Definition
migraine
Term
Headaches: Location: varies
Definition
varies with location of tumor
Term
Headaches: Location: localized in the eye and orbit and radiating to the facial and temporal regions
Definition
cluster headache
Term
Headaches: Location: usually located in the frontal, temporal, or occipital region
Definition
tension headache
Term
Headaches: Duration: commonly occurs in the morning and lasts for several hours
Definition
tumor related headache
Term
Headaches: Duration: lasts days, months, or years
Definition
tension headache
Term
Headaches: Duration: lasts up to 3 days
Definition
migraine
Term
Headaches: Duration: typically occurs in the late evening or night
Definition
cluster headache
Term
Headaches: Severity: throbbing, severe, recurring
Definition
migraine
Term
Headaches: Severity: dull, aching, tight, diffuse
Definition
tension headache
Term
Headaches: Severity: intense and stabbing
Definition
cluster headache
Term
Headaches: Severity: aching, steady, variable in intensity
Definition
tumor related headache
Term
Headaches: Associated Factors: occur more often in women
Definition
migraines
Term
Headaches: Associated Factors: occur more in young males
Definition
cluster headaches
Term
Headaches: Associated Factors: Which gender do tension headaches affect more often?
Definition
Tension headaches affect women more often than men.
Term
Do migraines commonly have a familial association?
Definition
yes
Term
Acromegaly occurs when there is an increased production of which hormone?
Definition
growth hormone, making bones larger and thicker
Term
Physical Assessment: Aortic insufficiency may cause what abnormality of the head and face?
Definition
an involuntary nodding movement
Term
Physical Assessment: The head tilted to one side may indicate...
Definition
...unilateral vision or hearing deficiency or shortening of the sternomastoid muscle.
Term
Physical Assessment: What facial abnormality may result from a CVA (cerebrovascular accident/sroke) or Bell's palsy (a neurologic condition)?
Definition
drooping of one side of the face
Term
cachexia
Definition
emaciation or wasting
Term
Inflammation of the temporal arteries may lead to...
Definition
...blindness.
Term
How do you assess the temporomandibular joint (TMJ)?
Definition
Place your index finger over the front of each ear as you ask the client to open her mouth.
Term
When assessing TMJ (temporomandibular joint) syndrome, be sure to explore the client's history of...
Definition
...headaches, if any.
Term
Prominence or swellings other than the __ vertebre may be abnormal.
Definition
C7
Term
kyphosis
Definition
an abnormal, convex curvature of the spine, with a resultant bulge at the upper back
Term
Normal Finding: Fat may accumulate around the cervical vertebrae (especially in women). This is sometimes called a...
Definition
..."dowager's hump."
Term
A human neck normally rotates how many degrees?
Definition
70 degrees
Term
Normally lymph nodes are what size and shape?
Definition
Normally lymph nodes are round and smaller than 1 cm and are not palpable.
Term
When lymph node enlargement exceeds 1 cm, the client is said to have _______________.
Definition
lymphadenopathy
Term
Lymphadenopathy may be caused by...
Definition
...acute or chronic infection, an autoimmune disorder, or metastatic disease.
Term
If one or two lymphatic groups enlarge, the client is said to have ________ _______________.
Definition
regional lymphadenopathy
Term
If three or more lymphatic groups enlarge, it is called ___________ _______________.
Definition
generalized lymphadenopathy
Term
Generalized lymphadenopathy that persists for more than 3 months may be a sign of...
Definition
...human immunodeficiency virus (HIV).
Term
Lymph node delimitation refers to...
Definition
...the lymph node's position or boundary.
Term
What is the most accurate method to determine heart rate and rhythm?
Definition
ascultation of the apical pulse
Term
Why is ascultation of the apical pulse the most accurate method to determine heart rate and rhythm?
Definition
You are listening directly over the heart, rather than depending on the transmission of the pulse to a distal site, such as the radial pulse site.
Term
The following memory device can be used to assist in obtaining information from the patient who has chest pain: PQRST... P
Definition
Precipitating Events: What events or activities precipitated the pain (eg, argument, exercise, resting)?
Term
Q
Definition
Quality of Pain: What does the pain feel like (eg, pressure, dull, aching, tight, squeezing)?
Term
R
Definition
Radiation of Pain: Where is the pain located? Does the pain radiate to other areas (eg, back, arms, jaw, teeth, shoulder, elbow)?
Term
S
Definition
Severity of Pain: Rate the pain on a scale of 0-10.
Term
T
Definition
Timing: When did the pain begin? Has the pain changed since this time? Have you had pain like this before?
Term
Pericarditis is a condition in which...
Definition
...the sac-like covering around the heart (pericardium) becomes inflamed. Symptoms: Chest pain is almost always present.
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: SUDDEN, USUALLY IN RESPONSE TO EXERTION, EMOTION, OR EXTREMES IN TEMPERATURE
Definition
Angina
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: SUDDEN, WITHOUT PRECIPITATING FACTORS, OFTEN IN EARLY MORNING
Definition
Myocardial Infarction
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: SUDDEN
Definition
Pericarditis
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: VARIABLE, MAY BE IN RESPONSE TO STRESS OR FATIGUE
Definition
Anxiety
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: VARIABLE
Definition
Pleuropulmonay or Esophageal-Gastric
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: SQUEEZING, HEARTBURN, VARIABLE SEVERITY
Definition
Esophageal-Gastric
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: INTENSE STABBING, VISELIKE PAIN OR PRESSURE, SEVERE
Definition
Myocardial Infarction
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: SQUEEZING, VISE-LIKE PAIN
Definition
Angina
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: DULL ACHE TO SHARP STABBING; MAY BE ASSOCIATED WITH NUMBNESS IN FINGERS
Definition
Anxiety
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: SHARP, STABBING, MODERATE TO SEVERE
Definition
Pericarditis
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: MODERATE ACHE, WORSE ON INSPIRATION
Definition
Pleuropulmonary
Term
5 parts of the sternum from superior to inferior
Definition
jugular notch, manubrium, sternal angle, body, xiphoid process
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: SUBSTERNAL; MAY SPREAD THROUGHOUT THE ANTERIOR CHEST AND TO THE ARMS, JAW, BACK, OR NECK
Definition
Myocardial Infarction
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: LUNG FIELDS
Definition
Pleuropulmonary
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: SUBSTERNAL; MAY SPREAD TO THE SHOULDERS OR THE ABDOMEN
Definition
Esophageal-Gastric
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: USUALLY THE LEFT SIDE OF THE CHEST WITHOUT RADIATION
Definition
Anxiety
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: SUBSTERNAL; USUALLY SPREADS TO THE LEFT SIDE OR THE BACK
Definition
Pericarditis
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: SUBSTERNAL; MAY SPREAD ACROSS THE CHEST AND THE BACK AND/OR DOWN THE ARMS
Definition
Angina
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: USUALLY LASTS A FEW MINUTES
Definition
Anxiety
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: USUALLY LASTS <15 MIN; RELIEVED WITH REST, NITRATE ADMINISTRATION, OR OXYGEN THERAPY
Definition
Angina
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: USUALLY LASTS 30 MIN OR LONGER OR IS RELIEVED WITH OPIOIDS
Definition
Myocardial Infarction
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: INTERMITTENT; RELIEVED WITH SITTING UPRIGHT, ANALGESIA, OR ADMINISTRATION OF ANTI-INFLAMMATORY AGENTS
Definition
Pericarditis
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: CONTINUOUS UNTIL THE UNDERLYING CONDITION IS TREATED OR THE CLIENT HAS RESTED
Definition
Pleuropulmonary
Term
Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: VARIABLE; MAY BE RELIEVED WITH ANTACID ADMINISTRATION, FOOD INTAKE, OR TAKING A SITTING POSITION
Definition
Esophageal-Gastric
Term
Which position provides the best exposure for inspection of the precordium?
Definition
a supine position with the chest exposed
Term
To assess for a left ventricular heave, the force of the impulse should be observed at which location?
Definition
left midclavicular line, 5th intercostal space. A left ventricular heave is seen at the apex. This forceful thrusting of the ventricle occurs with hypertrophy of the left ventricle.
Term
To begin palpation at the base of the heart, where should you palpate first?
Definition
right sternal border, 2nd intercostal space.
Term
The Heart: The right sternal border, 2nd intercostal space is the location of...
Definition
the aortic site. The aortic and pulmonic sites are found at the base of the heart.
Term
The nurse uses a stethoscope for auscultation of the client's heart, and plans to begin auscultation at the aortic area. How should the nurse plan to continue auscultation from that site?
Definition
inch the stehoscope across and down in a "Z" pattern
Term
During auscultation, you have difficulty distinguishing S1 from S2 because of the client's irregular heart rhythm. While continuing to listen at the aortic site, what action should you take?
Definition
Palpate the carotid artery pulse. S1 occurs simultaneously with the carotid artery pulsation. By gently palpating the carotid artery, you can distinguish S1 as the sound that occurs with each pulsation.
Term
What does a murmur sound like?
Definition
Murmurs are often heard as a swooshing sound.
Term
You hear a swooshing sound that coincides with S1 while listening with the diaphragm of the stethoscope. How should you identify this sound?
Definition
systolic murmur
Term
Systolic murmurs coincide with which heart sound?
Definition
Systolic murmurs coincide with the S1 heart sound.
Term
To determine the grade of the murmur, what action should you take?
Definition
Note how easily the murmur is heard by gradually lifting the stethoscope. Murmurs are graded from 1 to 6.
Term
S3 heart sound
Definition
A soft dull sound heard after S2 is an abnormal heart sound. This S3 heart sound is low pitched and is heard best at the apex with the bell of the stethoscope.
Term
An S3 heart sound may be an early indicator of...
Definition
...the onset of heart failure.
Term
After finding an S3 heart sound, what should you check for?
Definition
Check for jugular vein distention or other signs of heart failure. You would do this because an S3 heart sound may be an early indicator of the onset of heart failure.
Term
The nurse places the client supine in a Semi-Fowler's position. To inspect for jugular vein distention, what action should the nurse take?
Definition
remove the client's pillow and turn his head away slightly
Term
Which position allow you to measure the height of any jugular vein pulsations?
Definition
a semi-Flowler's position with the client's head turned slightly away
Term
Are venous pulsations palpable or not palpable?
Definition
not palpable
Term
Is a split S2 a normal finding or an abnormal finding?
Definition
A split S2 is a normal finding.
Term
A split S2 can be heard in some people as the result of...
Definition
...the slightly asynchronous closing of the aortic and pulmonic valves.
Term
A split S2 is heard best...
Definition
...during inspiration at the pulmonic site, the left 2nd intercostal space.
Term
Vital signs and oxygen saturation are within normal parameters. Radial pulse rhythm is irregular. Increasingly frequent periods of dyspnea, dizziness and minor chest discomfort. What assessment would you make next?
Definition
Determine if the client is currently experiencing angina because the client has a history of chest discomfort. Agina should be treated immediately to reduce the risk for myocardial damage.
Term
S1 ("lub") is caused by...
Definition
...turbulence caused by the closure of mitral and tricuspid valves at the start of systole.
Term
S2 ("dup") is caused by...
Definition
...the closure of the aortic and pulmonic valves, marking the end of systole.
Term
The time between the first heart sound (S1) and the second heart sound (S2) defines...
Definition
...systole (ventricular ejection).
Term
The time between the second heart sound (S2) and the following sound defines...
Definition
...diastole (ventricular filling).
Term
SBAR stands for...
Definition
Situation, Background,Assessment, Recommendations
Term
What are atrioventricular valve flaps anchored to?
Definition
papillary muscles within the ventricles
Term
What anchors atrioventricular valve flaps to papillary muscles within the ventricles?
Definition
collagen fibers called chordae tendineae