Health Assessment Exam 2
Terms
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- Delusion is an example of an abnormality of:
- thought content
- DF complains of "bugs" on a clean bed. This is an example of altered:
- perception
- What best describes the four major components of the mental status exam?
- Appearance, behavior, cognition, and thought processes
- Apraxia is best described as:
- the impaired ability to carry out motor activities despite intact motor function.
- Tense posture. Clothing clean;no shoes or coat with temperature in the low 40s describes what?
- appearance
- Abstract thinking is the ability to think
- hypothetically
- Blocking best illustrates what?
- This best illustrates an abnormality of thought process
- The Set Test is a supplemental test specifically used with
- aging adults.
- Orientation and attention span are categorized under
- cognitive function
- The purpose of the mental status exam is
- to determine mental health strengths, to determine coping skills & to screen for dysfunction.
- Behaviors assessed during the mental status examination include:
- consciousness, facial expression, speech, and mood.
- Use of the A-B-C-T guidelines is recommended for which age group?
- Individuals across the life span
- What are abdormalities often due to when testing children?
- Abnormal findings are often problems of omission or non-achievement of an expected developmental milestone.
- The development of thought process coincides with readiness for
- school.
- Aphasia is best described as
- a language disturbance.
- How can the diagnosis of dementia be differentiated from delerium?
- The diagnosis of dementia is dependent on presence of impaired social or occupational functioning
- A major characteristic of dementia is
- impaired short- and long-term memory.
- The four main headings during history and physical exam are
- appearance, behavior, cognition, and thought processes
- What may cause Delerium?
- Substance Abuse
- What are somet cognitive changes at age 7?
- more logical and systematic ablity to reason and understand
- what can inadvertently influence the interpretation of a mental status exam
- medication
- One way to assess cognition and detect dementia is with
- the Mini-Mental Status Exam.
- Unilateral neglect is the total inattention to one side of the body that is associated with
- cerebrovascular accidents
- Speech and mood fall under the category of
- behavior
- Language as a social tool coincides with
- cooperative play
- concern about a person's change in behavior, aphasia,and acute symptoms of mental illness are
- Indications for a full mental status exam include
- Grooming and hygiene fall under the category of:
- appearance.
- The Behavioral Checklist, which is completed by a parent/caretaker, assesses the mental status of:
- children 7 to 11 years of age.
- The Set Test specifically screens for:
- dementia.
- Agnosia is best described as:
- the impaired ability to recognize or identify objects despite intact sensory function.
- Additional assessments are required for the aphasic patient by asking the patient to demonstrate:
- word comprehension by naming articles in the room or on the body as you point to them.
- Language as a social tool coincides with a:
- child's readiness to play cooperatively.
- writing an original sentence would test for?
- aphasia
- Mental status assessment documents:
- dysfunction and how dysfunction impacts self-care.
- Memory impairment is best descried as:
- impaired ability to learn/recall prior learning despite absence of significant cog. impairment
- Dementia can best be described as:
- the development of multiple cognitive deficits.
- groups of axillary lymph nodes drains the other three
- Central
- what is the best description of Stage 3 breast development
- The nipple is flush with the surface of breast tissue.
- The glandular tissue of the breasts contains:
- milk-producing cells and collection/storage systems.
- The cone-shaped breast tissue that projects up into the axilla along the pectoral nodes is called:
- the tail of Spence.
- What are some common changes for pregnant women?
- nodularity, dark areolas with erect nipples, & a superficial, prominent venous pattern.
- What might a nurse expect to find in a breast exam of an 81 year old woman?
- palpable, firm, stringy lactiferous ducts.
- Spontaneous clear nipple discharge is common in
- women with a recent history of childbirth or breastfeeding.
- A 3 cm firm, fixed, irregular mass L tail of Spence would be suspicious of what?
- cancer
- A Supernumerary nipple is
- a normal breast variation
- a shallow dimple or skin tether apparent at rest or with arm lifting is
- Skin retraction
- pig-skin, orange peel, and peau d'orange are indicative of what?
- Lymphatic obstruction suggestive of cancer
- Spontaneous, unilateral serous or serosanguinous discharge from a single duct is most likely due to an:
- intraductal papilloma.
- Gynecomastia can accompany:
- Cushing's syndrome, hormonal treatment and other medications.cirrhosis of the liver, &
- Itching/burning/drawing pain with pasty, purulent nipple discharge & palpable ducts are symptoms of:
- mammary duct ectasia.
- An erythematous areolar halo and a crusted, eczematous retracted nipple are commonly found in:
- Paget's disease.
- Drainage from the central axillary nodes flow:
- into the infraclavicular and supraclavicular nodes.
- The number of lobes within the breast ranges between:
- 15 to 20.
- The smallest structure of the mammary gland is the:
- alveolus
- The lactiferous sinuses are:
- the milk storing reservoirs.
- The breast is composed of glandular tissue, adipose tissue, and:
- fibrous tissue.
- Suspensory ligaments are supportive fibrous bands that:
- extend vertically from the surface and attach to muscles of the chest wall.
- The relative proportion of glandular/fibrous/adipose breast tissue depends on:
- nutritional status/ reproductive stage/gender
- The most common site of cancerous breast tumors is in the:
- upper outer quadrant.
- Describe the lymphatic drainage system of the breast
- The central axillary nodes drain in the infraclavicular supraclavicular nodes
- Where do the majority of lymph drain?
- Into the ipsilateral axillary nodes
- What does the breast consist of at birth?
- lactiferous ducts within the nipple.
- At puberty, what changes does estrogen cause in the breast?
- enlargement/ductal system development/Alveoli mature
- Menarche occurs during which stage of breast development?
- 3 or 4
- Colostrum is present starting
- about the twelfth week of pregnancy
- What happens to the breasts post-menopause?
- Glandular tissue decreases/ Fibrous connective tissue increases/Fat tissue atrophies
- Mastalgia or breast pain commonly occurs with:
- trauma, inflammation, and infection.
- Slight crusting of the nipple apex that spreads to the areola is suspicious of:
- Paget's disease.
- What breast lump characteristics should the examiner document?
- Size, shape, consistency, tenderness, and skin appearance of the breast
- What patient maneuvers help the examiner to see retraction or dimpling?
- Pushing the palms of the hands together
- What is the lifetime risk of breast cancer for men?
- The lifetime risk of developing breast cancer is 1 in a 100.
- Signs suspicious of breast cancer include:
- skin dimpling or retraction.
- women 20-39 should have one of these every 3 years
- clinical breast exam
- This kind of pain is common in women who take oral contraceptives
- cyclic
- decreased breast firmness and shrinkage is expected after
- menopause
- Nipple discharge is known as
- Galactorrhea
- Determining the pattern of factors that might contribute to breast cancer is called
- a risk profile
- breast pain that occurs with trauma or benign breast disease is called
- mastalgia
- This is normal compressed breast tissue/ not a lump
- inframammary ridge
- enlargement of male breast tissue
- gynecomastia
- description of breast tissue as hard/soft/ or firm is called?
- consistancy
- an extra nipple located below the breast:
- supranumerary
- early breast development with no other secondary sex characteristics present
- Thelarche
- this finding should be distinguised from nipple inversion
- nipple retraction
- this is a passive process that occurs when the diaphram relaxes and squeezes the lungs
- expiration
- maintaining an acid base balance in the arterial blood employs this mechanism:
- homeostasis
- This rapid breathing causes CO2 to be blown off
- hyperventilation
- air rushes into lungs and then is exhaled from lungs
- respiration
- shallow form of breathing that leads to CO2 build up in blood
- hypoventilation
- this is the normal stimulus to breathe
- hypercapnea
- this is supplied to blood to enhance energy production
- oxygen
- what qudrant are the liver/gallbladder located
- RUQ
- what qudrant are the cecum and appendix located
- RLQ
- An enlarged spleen may be confused with what?
- An enlarged kidney
- Where is the left kidney usually palpable?
- right below the ribcage
- The-----is not palpable unless it is 3x's its normal size
- spleen
- Auscultation of the normal abdomen should yeild
- perisystolic sounds
- Hooking is the technique common in palpating the...
- liver
- The size of a normal liver in the adult is .......cm
- 6-12
- dullness when percussing the bladder indicates
- distention
- the pattern of pubic hair in the adult male is
- diamond
- a visible bulge on the ab. of a newborn is known as
- diastasis recti
- silvery-white jagged lines commonly seen on the Ab. are called
- linea albinates
- a constant board like hardness of the ab. muscles as a result of inflamation of the peritoneum is
- involuntary rigidity
- predominate percussive sound heard over a gasseous distended abdomen:
- hyper-ressonance
- eating of chips of paint, grass, or clay common in children or pregnant women
- pica
- a shifting dullness on palpation of ab is an indication of
- ascites
- enlarged liver on palpation
- hepatomegaly
- uniformly rounded belly/sunken umbilicus/ normal BS tymp. and palp.
- obesity
- localized distention/norm.bs/ dull areas of percussion/ defined borders on palpation
- tumor