NUR2092 Health Assessment Exam 2

NUR2092 Health Assessment Exam 2 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, 2 nd 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, 2 nd intercostal space.

What are you hearing when listening to S2?