Health Assessment Exam 1

In order, the nursing process goes:
1) ❌
2) ❌
3) ❌
4) ❌
5) ❌

A ❌ is a subjective sensation that the person feels from the disorder.

A ❌ is an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports.

Match the present health critical characteristic to it's definition:

❌: Be specific; ask the patient to point to the location.
❌: This calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike.
❌: Attempt to quantify the sign of symptom. Use a pain scale to quantify pain.
❌: Onset, Duration, Frequency. When did the symptom first appear?
❌: Where was the person or what was the person doing when the symptom started?
❌: What makes the pain worse? What seemed to help?
❌: Is this primary symptom associated with any others?
❌: Find out the meaning of the symptom by asking how it affects daily activities.

What does the mnemonic PQRSTU for asking patient perception of a symptom stand for?

P: ❌ or ❌
Q: ❌ or ❌
R: ❌ or ❌
T: ❌
U: ❌

Match the observation of the component of the mental status exam to the definition:

❌: The patient is sitting erect and relaxed.
❌: What the patient is saying makes sense.
❌: The patient is awake, alert, and aware of stimuli.
❌: Patient is oriented to time, place, and person.

Match the observation of the component of the mental status exam to the definition:

❌: The patient is able to complete a thought, able to recall recent and remote memories.
❌: The patient is consistently aware of reality.
❌: The patient's facial expressions change appropriately and laryngeal speech is effortless.
❌: Body movements are voluntary and deliberate.

❌ is a temporary expression of feelings or state of mind.

❌ is the more durable, prolonged display of feelings that color the whole emotional life.

Match the mental status abnormal posture finding to it's definition:

❌ or ❌: Sitting on edge of chair or curled in bed, tense muscles, frowning, darting and watchful eyes, and restless pacing.

❌ or ❌: Sitting slumped in chair, slow walk, dragging feet.

Match the mental status abnormal body movement finding to it's definition:

❌: Abnormal posturing and bizarre gestures.

❌ or ❌: Apathy and psychomotor slowing.

❌: Restless, fidgety movement or hyper-kinetic appearance.

Match the Level of Consciousness to it's definition:

❌: Sleeps most of the time; difficult to arouse - needs loud shout or vigorous shake; acts confused when aroused; speech may be mumbled or incoherent.

❌: Awake or readily aroused; oriented, fully aware of external and internal stimuli and responds appropriately.

❌: Spontaneously unconscious; responds only to persistent and vigorous shake or pain; has appropriate motor response; otherwise can only groan, mumble, or move restlessly.

❌: Not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in a normal voice but looks drowsy; responds appropriately but inattentive.

❌: Completely unconscious; no response to pain or any external or internal stimuli.

❌: Clouding of consciousness; inattentive; incoherent conversation; impaired recent memory, often agitated and having visual hallucinations.

Match the screening to the definition:

❌: Screen for core anxiety symptoms.

❌: Screen for depressed mood and anhedonia.

❌: Screen for detecting developmental delays in infants and preschoolers.

Match the type of aphasia to the condition:

❌ The most common and severe form. Spontaneous speech is absent or reduced to a few stereotyped words or sounds. Comprehension is absent or reduced to the person's own name and a few select words.

❌: Expressive aphasia. The person can understand language but not express himself or herself using language. This is characterized by nonfluent, dysarthric, and effortful speech.

❌: Receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated but has many paraphasias and neologisms and often lacks substantive words.

Match the abnormal mood and affect to the clinical example:

❌: Topic varies, expression does not.

❌: Fear of flying in airplanes.

❌: "I feel nervous and high-strung. I worry all the time."

❌: Person expresses euphoric, tearful, angry feelings in rapid succession.

❌: "I don't feel real. I feel like I'm not really here."

❌: Person has expressed violence toward self or others.

❌: Laughs while discussing admission for liver biopsy.

❌: "I feel on top of the world!"

❌: "I've got the blues."

❌: A person feels love and hate toward another person at the same time.

❌: "I'm feeling very happy."

❌: Person internalizes a feeling of tension, and a seemingly mild stimulus "sets him or her off"

Match the correct mental disorder to the definition:

❌: An acute confusional state, potentially preventable in hospitalized persons. Characterized by disorientation, disordered thinking perceptions, defective memory, agitation, inattention.

❌: A chronic progressive loss of cognitive function and intellectual functions, although perception and consciousness are intact. Characterized by disorientation, impaired judgement, memory loss.

❌: A long-term depressed mood, with a lack of pleasure; disturbed sleep and appetite; feelings of hopelessness, guilt, worthlessness, sadness, loneliness, and despair; suicide ideation.

Match the abnormal thought process to the clinical example:

❌: "Forgot what I was going to say."

❌: Gives detailed description of his long walk around the hospital although you know patient remained in his room all afternoon.

❌: "I have to turn on my thinkilator."

❌: Says "the thing you open the door with" instead of "key".

❌: "When was my surgery? Well I was 28, I was living with my aunt, she's the one with psoriasis, she had it bad that year because of the heat, the heat was worse then than it was the summer of '92..."

❌: "My boss is angry with me, and it wasn't even my fault. (pause) I saw that movie too, Lassie. I felt really bad about it. But she kept trying to land the airplane and she never knew what was going on."

❌: "Take this pill? The pill is blue. I feel blue. (sings) She wore blue velvet."

❌: "Beauty, red-based five, pigeon, the street corner, soft of."

❌: "I'm going to lock the door, lock the door. I walk every day, and I lock the door. I usually take the dog, and I lock the door."

❌: Nurse, "I want you to take your pill." Patient (mocking), "Take your pill. Take your pill."

❌: "My feet are cold. Cold, bold, told. The bell tolled for me."

Match the characteristics of an eating problem to the definition:

❌: Recurrent episodes of uncontrollable binging followed by inappropriate compensatory behaviors (vomiting, laxatives, diuretics).

❌: Intense fear of weight gain, restricted caloric intake.

❌: Recurrent episodes of uncontrollable binging without compensatory behaviors.

Where would you expect to hear the following characteristics of percussion notes?

❌: Over normal lung tissue.
❌: Normal over child's lung (abnormal in adult), increased amount of air as in emphysema.
❌: Over air-filled viscus (stomach, intestine)
❌: Relatively dense organ as lives or spleen.
❌: When no air present, over thigh muscles or bone or over tumor.

What part of the hand is used for what part of palpation?

❌: Fine tactile discrimination (skin texture, swelling, pulsation, lumps)
❌: Detect position, shape, and consistency of an organ or mass.
❌: Determine temperature.
❌: Vibration.

Match the heart rate diagnosis to the definition:

❌: The adult has a resting heart rate of less than 50 beats/min.
❌: The adult has a resting heart rate of greater than 95 beats/min.
❌: The heart varies with the respiratory cycle, speeding up and slowing down.

The first sound heard after beginning to deflate the blood pressure cuff is the ❌ pressure.

The last audible sound heard after deflating the blood pressure cuff is the ❌ pressure.

Match the abnormal skin coloring to the definition:

❌: The skin takes on the color of connective tissue, which is mostly white.
❌: Intense redness of the skin from excess blood in dilated superficial capillaries.
❌: Blueish mottled color from decreased perfusion.
❌: A yellowish skin color indicates rising amounts of bilirubin in the blood.

Match the abnormal skin coloring to the condition it could indicate:

Pallor: ❌
Erythema: ❌
Cyanosis: ❌
Jaundice: ❌

Match the population at risk to the condition:

Neonates: ❌
Adolescents: ❌
Pregnant Woman: ❌
Older Adults: ❌.

Match the description of the common shapes and configurations of lesions to the definition:

❌: circular, begins in center and spreads to periphery
❌: lesions run together
❌: individual lesions that remain seperate
❌: twisted, coiled spiral, snakelike
❌: clusters of lesions
❌: a scratch, streak, line, or stripe
❌: iris, concentric rings of color in lesions
❌: linear arrangement along unilateral nerve route
❌: annular lesions grow together

Match the skin etiology to the observation:

❌: whitish, creamy, pink color throughout the integument.
❌: Patchy milky-white spots, often symmetric bilaterally.
❌: Yellow-orange tinge.
❌: Orange-green or gray overlying pallor of anemia.
❌: Bronzed appearance, especially around trunk.
❌: Tan to light brown, irregular shaped, oval patch.

Match the primary skin lesion to its definition:

❌: Solely a color change, flat and circumscribed, less than 1 cm.
❌: Something you can feel, solid, raised, circumscribed, less than 1 cm.
❌: Macules that are larger than 1 cm.
❌: Surface elevation that is pleateaulike, wider than 1 cm.
❌: Solid, elevated, hard or soft, not fluid filled, larger than 1 cm.
❌: Superficial, raised, transient, and erythematous, slight irregular shape.
❌: Larger than a few cm's in diameter.
❌: Elevated cavity containing free fluid, up to 1 cm.
❌: Larger than 1 cm diameter, fluid filled.
❌: Encapsulated fluid-filled cavity in dermis, elevating skin.
❌: Turbid fluid in the cavity. Circumscribed and elevated.

Match the secondary skin lesion to its definition:

❌: Thickened, dried-out exudate left when vesicles/pustules dry up.
❌: Compact, desiccated flakes of skin, dry or greasy, silvery or white.
❌: Linear crack with abrupt edges, deep into dermis.
❌: Scooped out but shallow depression.
❌: Deeper depression extending into dermis, irregular shape.
❌: Self-inflicted abrasion.
❌: After tissue repair, collagen replaces normal tissue.
❌: Skin level is depressed with loss of dermis.
❌: Prolonged exposure to irritant thickens skin, becomes leathery.
❌: Excess of scar tissue beyond sites of injury.