NUR2092 Health Assessment Exam 2 Questions and Answers for .

NUR2092 Health Assessment Exam 2 Questions and Answers () If you are doing a cardiovascular assessment and you are hearing a bruit/swooshing sounds in the patients carotid artery, what does this mean? -Narrow vessel (Most likely filled with plaque buildup) If you are doing a Snellen eye exam from 20 feet away what are you testing? -Farsided eye sight What are 4 things that the skin does? -Prevention of penetration, temperature regulation, absorbs Vitamin D and wound repair (repairs itself) What cannot the skin do? -Prevent the loss of fluids When you are doing a lung assessment you should listen from what direction to what direction? -Right to left What is the Jaeger card used for? -Testing nearsided eye sight If a mole on a patients skin has abnormal pigmentation and is itchy, at what size does the mole become suspicious? -6mm What are you listening for when listening to bowel sounds? -Gurgling If you do not hear any sounds after 1 minute of listening to bowel sounds, what do you do? -Listen for 4 more minutes for a total of 5 minutes. What is a hypoactive bowel sound? -A distant bowel sound (Likely constipation. Only hearing gurgles every 1-2 minutes) What is an indication if a patient has yellow skin? -Jaundice. A liver problem If you are palpating lymph nodes in front of the ear, what lymph nodes are you palpating? -Preoricular If you are doing an abdominal assessment and you only heat a few gurgles every 1-2 minutes, what should you suspect is going on with the patient? -Constipation What should you always ask a patient when doing an abdominal assessment? -When was your last bm (No bm in 3 days indicates constipation) What is cyanoisis? -No oxygen exchange Which of the following patients would take highest priority: Jaundice yellow skin, Pale skin and vomiting or Cyanotic? -Cyanotic (Patient is not getting proper amounts of oxygen exchange) What are some good assessment questions to ask someone that may be having an allergic reaction? -Have you been using any new soaps, lotions, detergent, etc. When assessing radial pulses, what is it important to do? -Assess one side to the other (Should feel both sides at same time to compare) What sounds will you hear while doing a lung assessment on a patient with an upper airway obstruction? -Stridor. This is an upper airway emergency! When resulting a TB skin test what would you be looking and feeling for if it was irregular? -Red, raised bump/wheal. Greater than 5mm is positive, pink patches What sounds will you hear while doing a lung assessment on a patient with a lower airway obstruction? -Wheezes How long should the skin take to turn back to pink when assessing capillary refill? -Less than 3 seconds (2 seconds or less) If capillary refill takes more than 2 seconds to turn from pink to white, what is this called? -Sluggish or slow If capillary refill takes less than 2 seconds to turn from white to pink, what is this called? -Brisk If doing an assessment you notice that the patient tonsils are touching their uvula, is this an abnormal or normal finding? -Abnormal (Tonsillitis) What should you do if you are testing a patients hearing acuity and gross hearing ability? -Have patient shut their eyes to hear better and so that they cannot see your hands. Rub your fingers next to their ear to assess. The patient must verbalize that they hear the sound of your fingers rubbing together. What order do you assess bowel sounds? -Look, listen, then feel/palpate Why must you listen to bowel sounds before palpating? -Always listen before touching because when you palpate, you can move things around in the abdomen and get a false assessment if listening right after. Which heart sound is the loudest? -S1 Where do you hear S1 heart sounds? -On the right side of the chest, 2nd intercostal space. What are you hearing when listening to S1? -Closure of AV valves. Mitral and biscuspid. Lub sound Where do you hear S2 heart sounds? -On the left side of the chest, 2nd intercostal space. What are you hearing when listening to S2? -Closure of SL valves. Aortic and Pulmonic. Dub sound Where can you hear both S1 and S2? -Erbs Point. Left side of chest, 4th intercostal space What are the 2 phases of the cardiac cycle? -Systole and Diastole In order to feel a patients carotid pulse, where must you feel? -Right by the SCM on the side of the neck. Do NOT feel both sides at the same time. When you are assessing a patients lung sounds, where are normal bronchovascular breath sounds heard? -Next to sternal border If a patient is SOB and cannot breathe while in a lying position what does this patient have? -Orthopnea How should a patient with orthopnea be positioned? -Sitting up with their arms up. (Tripod position) This expands their lungs to make breathing easier. What should you do if you feel an irregular radial pulse? -Listen to an apical heart rate for 1 full minute When doing a thoracic assessment what do you look for first? -Look for chest movement. Make sure that chest is expanding symmetrically. When you are percussing a patients back at the costoverterbral angle, what are you checking for? -Kidney tenderness What is it called when a patient is sitting upright and their jugular vein is enlarged? -Jugular Vein Distention (JVD) What does it mean if a patient has Jugular Vein Distention (JVD)? -Increased blood volume, generally congestive heart failure