HEALTH ASSESSMENT REVIEWER PART 1&2

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of
the sole and across the ball of the foot,
the nurse notices the plantar flexion of the toes. How should the nurse document this finding?
a. positive Babinski sign
b. plantar reflex abnormal
c. plantar reflex present
d. plantar reflex "2+" on a scale from "0-4+"
During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the
patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of
air when the nurse presses against the right puffed cheek.
This would indicate dysfunction of which of these cranial nerves?
a. motor component of IV
b. motor component of VII
c. motor and sensory components of XI
d. motor component of X and sensory component of VII

The nurse places a key in the hand of a patient and he identifies it correctly. What term would the nurse
use to describe this finding?
a. extinction
b. stereognosis
c. graphesthesia
d. tactile discrimination

A patient has been in the intensive care unit for 10 days. He has just been moved to the
medical-surgical unit, and the admitting nurse
is planning to perform a mental status examination on him. During the tests of cognitive function
the nurse would expect that he:
a. may display some disruption in thought content
b. will state " I am so relieved to be out of intensive care"
c. will be oriented to place and person but may not be certain of the date
d. may show evidence of come clouding of his level of consciousness

During the history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse
would document this as:
a. vertigo
b. syncope
c. dizziness
d. seizure activity

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black
combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink
with black streaks throughout. She has several pierced holes in her nares and ears and is
wearing an earring through her eyebrow and heavy black makeup.
The nurse concludes:

a. she probably doesn't have any problems at all

b. she is just trying to shock people and her dress should be ignored
c. she has manic syndrome because of her abnormal dress and grooming
d. that more information should be gathered to decide whether her dress is appropriate
The nurse is preparing to do a mental status assessment. Which statement is true regarding the
mental status assessment?
a. a patient's family is the best resource for information about the patient's coping skills
b. it is usually sufficient to gather mental status information during the health history interview
c. it takes an enormous amount of extra time to integrate the mental status examination into the
health history interview
d. it is usually necessary to perform a complete mental status examination to get a good idea of
the patient's level of functioning
A woman brings her 70 year old husband to the clinic for an examination. She is particularly
worried because after a recent fall, he seems to have lost a great deal of his memory of recent
events. Which statement reflects the nurse's best course of action? The nurse should:
a. plan to perform a complete mental status examination including the cranial nerves and
cerebellar function
b. refer him to a neurologist
c. plan to integrate the mental status examination into the history and physical examination
d. reassure his wife that memory loss after a physical shock is normal and will subside soon
During an examination, the nurse can assess mental status by which activity?
a. examining the patient's electroencephalogram
b. Observing the patient as he or she performs an IQ test
c. Observing the patient and inferring health or dysfunction through an assessment of behaviors
d. Only examining the patient's response to a specific set of questions

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes
closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as
a(n):
a. ataxia
b. lack of coordination
c. negative Homans' sign
d. positive Romberg sign

A woman who has lived in the United States for a year after moving from Europe has learned to
speak English and is almost finished with her college degree. She now dresses like her peers
and says that her family in Europe would hardly recognize her. This nurse recognizes that this
situation illustrates which concept?
a. Assimilation
b. Heritage consistency
c. Biculturalism
d. Acculturation

During palpation, what type of palpation should you start with and why? What steps are next?
1. start with LIGHT palpation to detect surface characteristics and accustom a person to being touched

-1 cm

2. then deeper palpations when needed

-intermittent pressure better than one long continuous palpation

-5 to 8 cm or 2-3 in

ALSO: bimanual palpation- requires the use of both hands to envelop or capture certain body parts or
organs such as kidneys, uterus, or adnexa for precise delimitation

What occurs during percussion, the third step?

-consists of tapping a person's skin with short, sharp strokes to assess underlying structures

What uses does percussion have?

-mapping location and size of organs

-signaling density of a structure by a characteristic note

-detecting a superficial abnormal mass

1. percussion vibrations penetrate about 5 cm

deep

2. deeper mass would give no change in percussion

-eliciting pain if the underlying structure is inflamed

-eliciting deep tendon reflex using percussion hammer

HOLLOW (AIR-FILLED) ORGANS SOUND DIFFERENT THAN SOLID ORGANS

...

What are the two methods of percussion?

1. Direct, or immediate, which is when the striking hand directly contacts the body wall

2. Indirect, or mediate, is when you use both hands and the striking hand contacts the stationary hand
fixed on the person's skin
In regards to percussion, what is resonance and where does it occur?

Resonance is low pitch and it occurs over normal lungs

In regards to percussion, what is hyper resonant and where does it occur?

Hyperresonant is lower pitch and it occurs over a child's lungs

In regards to percussion, what is tympany and where does it occur?

Tympany is high pitch and it occurs over air-filled organs (stomach, intestines)

In regards to percussion, what is dull and where does it occur?

Dull is high pitch and it occurs over solid organs (liver, spleen)

In regards to percussion, what is flat and where does it occur?

Flat is high pitch and it occurs where no air is present such as over muscles/bones or a tumor

What occurs during auscultation, the fourth step?

Auscultation is when you listen to sounds produced by the body

-most sounds are soft and must be channeled through a stethoscope

-once you can recognize normal sounds, you can distinguish the abnormal sounds and "extra" or
abnormal sounds

What is the single most important step in decreasing microorganism transmission?

WASH YOUR HANDS

-before physical contact with each patient

-after inadvertent contact with blood, body fluids, secretions, and excretions

-after contact with any equipment contaminated with body fluids

-after removing gloves

What else should you do in health care in addition to washing your hands?

WEAR GLOVES

-any time there is contact with body fluids

The nurse is assessing the abdominal region. What is the appropriate sequence for the examination?

1. Palpation, percussion, inspection, auscultation

2. Inspection, palpation, auscultation, percussion

3. Inspection, auscultation, percussion, palpation

Are vital signs subjective or objective data?

Objective because they can be measured by a health care professional

What are the 5 vital signs?

1. Temperature

2. Pulse

3. Heart rate

4. Respirations

5. Blood pressure

What are the benefits of taking temperature orally?

-It is accurate and convenient

-The oral sublingual site has a rich blood supply from the carotid arteries that quickly responds to
changes in inner core temperature

What is a normal oral temperature range?

98.6 degrees F (37 degrees C) with a range of 96.4 degrees F to 99.1 degrees F (35.8 to 37.3 degrees C)

What is a normal rectal temperature range?

Rectal measures 0.7 to 1 degrees F (0.4 to 0.5 degrees C) higher

What is normal temperature influenced by?

-Exercise: moderate to hard exercise increases body temp

-Age: wider normal variations occur in infants and young children due to less effective heat control
mechanisms; in older adults, the temperature is usually lower than in other age groups, with a mean of
97.2 degrees F (36.2 degrees C)

In regards to taking a temperature, how long should you wait if the patient has just consumed hot or
iced liquids? What about if they just smoked?

Liquids- 15 minutes

Smoking- 2 minutes

What is a safe and accurate way to take children's temperature?

Axillary temperature

When should you take a rectal temperature?

-When other routes are not practical, for example, for comatose or confused persons, persons in shock,
or for those who cannot close their mouth because of breathing or oxygen tubes, wired mandible, or
other facial dysfunction, or if no tympanic membrane thermometer is available

What should you do before inserting the thermometer probe into the rectum?

-Put on gloves

-Use lube

How should the temperature be recorded?

-In celsius, unless the agency uses Fahrenheit

What is the conversion from Fahrenheit to Celsius?

Celsius to Fahrenheit?

F to C: C = 59(F-32) or C = F-32+1.8

C to F: F = (95 x C) + 32 or F = 1.8(C) + 32

Know both Fahrenheit and Celsius scales and normal ranges ***

...

What is stroke volume?

What is normal in adults?

The amount of blood every heartbeat pumps into the aorta

-70 mL

Regarding pulse as a vital sign, what does palpating the peripheral pulse do?

It gives the rate and rhythm of the heartbeat, as well as local data on the condition of the artery

When is the radial pulse usually palpated?

When vital signs are measured

What should you use and where should you palpate the radial pulse?

-Use your first three fingers

-Palpate it at the flexor aspect of the wrist laterally along the radius bone

-Push until the strongest pulsation is felt

If the heart rhythm is REGULAR, how long should you count the number of beats for?

-30 seconds and multiply it by 2

Why are 30 seconds used to take the pulse?

because it is the most accurate and efficient when heart rates are normal or rapid and when rhythms
are regular

How long should you count the pulse if the rhythm is IRREGULAR?

1 full minute

-as you begin counting intervals, start your count with "zero" for the first pulse felt

What parts of a pulse should you assess?

-rate

-rhythm

-force

-elasticity

What is the normal heart rate range in a resting adult?

50 to 90 beats per minute

What causes the heart rate to vary?

-age (more rapid in infants and children but more moderate during adult and older years)

What is tachycardia?

-A more RAPID heart rate, over 90 bpm

-occurs with anxiety or with increased exercise to match the body's demand for increased metabolism

What is bradycardia?

-A SLOWER heart rate, less than 50 bpm

-occurs in a well-trained athlete

What is the force of the pulse?

Strength of heart's stroke volume

What does a weak, thready pulse reflect?

A decreased stroke volume

What does a full, bounding pulse indicate?

Increased stroke volume

-Such as anxiety, exercise, and some abnormal conditions

What kind of scale is pulse recorded on? What do the numbers indicate?

-A three-point scale

3+ full, bounding

2+ normal

1+ weak, thready

0 absent

-some agencies use a four-point scale

"90 bpm 2+"

What should someone's breathing be like? How should you monitor respiration?

-relaxed, regular, automatic, and silent

-instead of telling someone you are monitoring their respiration, maintain your position of counting
radial pulse and count respirations

How long should you count respirations?

-Count for 30 seconds or 1 minute if you suspect an abnormality

What is the ratio of pulse rate to respiratory rate?

4:1
-normally both rise as a response to exercise or anxiety

What is blood pressure defined as?

Force of blood pushing against the side of its container, vessel wall

What is systolic pressure? Diastolic?

Systolic: maximum pressure felt on artery during LEFT VENTRICULAR CONTRACTION or systole

Diastolic: elastic recoil, or resting, a pressure that blood exerts constantly between each contraction

What is mean arterial pressure, or map?

pressure forcing blood into tissues, averaged over the cardiac cycle, measured as diastolic (systolic-
diastolic) /3 or diastolic pressure + 1/3 pulse pressure

What is average blood pressure in adults?

120/80 mm Hg

-varies with factors such as age (rise into adult years), gender (females lower than males until after
menopause then it switches), race (African American usually higher than white)

Arm pressure, a person may be sitting or lying, with a bare arm supported at heart level. What are the
steps for taking blood pressure?

1. Palpate brachial artery; with the cuff deflated, center it about 1 inch above a brachial artery and wrap
it

2. Palpate brachial artery

3. Inflate the cuff until artery pulsation obliterated and then 20 to 30 mm Hg beyond

4. Deflate cuff quickly and completely; wait for 15 to 30 seconds before reinflating so blood trapped in
veins can dissipate
What is a blood pressure cuff called? How many sizes are there?

Sphygmomanometer

-6 sizes

What should the dimensions of the rubber bladder on the BP cuff be?

-About 40% the width of the person's arm and the length should be 80% of this circumference

-Should cover 70% of an arm from acromion to olecranon

If the BP cuff is too narrow/small, what can the reading be?

Falsely high, up to 50 mm Hg

If the BP cuff is wrapped too loosely, what can the reading be?

Falsely high

If the BP cuff is too large, what can the reading be?

Falsely low

When should you not use an automatic BP cuff?

-If systolic < 90 mm Hg, irregular heart rate, shivering, tremors, or seizures

Orthostatic, or postural vital signs: when should you take serial measurements of pulse and blood
pressure?

-you suspect volume depletion

-a person known to have hypertension or taking antihypertensive medications

-person reports fainting or syncope

How should you take postural vital signs?

-Have the person rest supine for 2 or 3 minutes and take baseline readings of pulse and BP

-Repeat with the person sitting

-Repeat with the person standing

-LYING, SITTING, STANDING

When should you take orthostatic, or postural vital signs?

-When the position changed from supine to standing, a normally slight decrease (less than 10 mm Hg) in
systolic pressure may occur

-Record BP by using even numbers

-Also record the person's position, arm used, and cuff size, if different from the standard size cuff

What is orthostatic hypertension?

B/P systolic drop of 20 mm Hg or increase in pulse by 20 beats/min with a quick change to standing

How should you weigh an infant?

-on a platform-type balance scale

-by age 2 or 3, use an upright scale

How should you measure an infant's body length?

Measure it supine by using a horizontal measuring board

What is the best index of a child's general health?

Physical growth***

Arteries, aorta, away, oxygen

...

Study measurement of oxygen saturation

...
What is a normal range of SpO2 for someone with no lung disease and no anemia?

-97 to 99%

-greater than 95% with normal hemoglobin

At lower oxygen saturations, what is more, accurate than the pulse oximeter?

An earlobe probe is more accurate and less affected by peripheral vasoconstriction

What is a general survey?

study of the whole person

What does a general survey cover?

Covers general health state and any obvious physical characteristics

You should launch a general survey every moment you first encounter someone or a situation. What are
some things you should look for?

What leaves an immediate impression?

-Does the person stand promptly as his or her name is called and walk to meet you? Or do they look
sick, rising slowly, with shoulders slumped and eyes downcast?

-Is a hospital patient conversing with visitors, involved in reading or television, or lying perfectly still?

As you proceed through your health history, measurements, and vital signs, note the following points
that will add up to the general survey. What are the four areas you should be aware of during a GS?

-physical appearance

-body structure

-mobility

-behavior

What does physical appearance consist of?

-age: person appears his or her stated age

-sex: sexual development appropriate for gender and age

-level of consciousness: person alert and oriented, attends to your questions, and responds
appropriately

-skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious
lesions

What does body structure consist of?

-facial features: symmetric with movement

-no signs of acute distress present

-stature: height appears within the normal range for age, genetic heritage

-nutrition weight appears within the normal range for height and body build; body fat distributed even

-symmetry: body parts look equal bilaterally and are in relative proportion

posture: person stands comfortably erect as appropriate for the age