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Health Assessment Exam 2


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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:
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?
Abstract thinking is the ability to think
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
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
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
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:
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:
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?
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
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?
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:
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
decreased breast firmness and shrinkage is expected after
Nipple discharge is known as
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
This is normal compressed breast tissue/ not a lump
inframammary ridge
enlargement of male breast tissue
description of breast tissue as hard/soft/ or firm is called?
an extra nipple located below the breast:
early breast development with no other secondary sex characteristics present
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
maintaining an acid base balance in the arterial blood employs this mechanism:
This rapid breathing causes CO2 to be blown off
air rushes into lungs and then is exhaled from lungs
shallow form of breathing that leads to CO2 build up in blood
this is the normal stimulus to breathe
this is supplied to blood to enhance energy production
what qudrant are the liver/gallbladder located
what qudrant are the cecum and appendix located
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
Auscultation of the normal abdomen should yeild
perisystolic sounds
Hooking is the technique common in palpating the...
The size of a normal liver in the adult is
dullness when percussing the bladder indicates
the pattern of pubic hair in the adult male is
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:
eating of chips of paint, grass, or clay common in children or pregnant women
a shifting dullness on palpation of ab is an indication of
enlarged liver on palpation
uniformly rounded belly/sunken umbilicus/ normal BS tymp. and palp.
localized distention/ dull areas of percussion/ defined borders on palpation

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