NUR 3029: Health Assessment Final Exam: Study Guide
The comprehensive examination will contain 100 multiple questions. Please refer to your course syllabus regarding examination policies, the Activities & Assignments for reading assignments, previous study guides, and class schedule. The following study guide is intended to assist you in preparing for the examination and may not be all-inclusive. Students are expected to apply concepts from pre-requisite courses. Examination preparation should include attending class lectures, reading assignments, and web-
based activities. Introduction to Health Assessment Understanding the components of the Nursing Process
Nurse’s role in environmental assessment
Communication for assessment of multiple populations (adult/elderly)
Cultural sensitivity in Health Assessment
Health History Communication during the physical examination and obtaining health history
Obtaining subjective and objective information during the health history
Components of the Health History
Assessment Techniques > Parts of the stethoscope and assessment of sounds (bell vs diaphragm)- the bell is used for soft, low pitched sounds such as extra heart sounds or murmurs and diaphragm used for high-pitched sounds such as, breathe, bowel, and normal heart sounds.
> Inspection, palpation, percussion, auscultation (order changes in abdominal assessment.
> Appropriate sequence of assessment (infant, child, adult)- the same for each- head to toe
General Survey Assessment of vital signs (normal vs abnormal, routes & locations of vital signs )
1) Temperature-
> normal oral temp: 96.8 degrees F; normal range: 35.8 to 37.3 degrees C (96.4-99.1 degrees F)- most accurate and convenient
> normal rectal temp: 0.4 to 0.5 degrees C higher (0.7 to 1 degree F)- only used when other routes
are not practical
> TMT- temperature checked by ear (used mostly in children)
2) Pulse- palpating the peripheral pulse gives the rate and rhythm of the heartbeat, as well as local data on
the condition of the artery; counting for 30 seconds and multiplying by 2 is the most accurate but if rhythm is irregular, count for the full minute; assess for rate, rhythm, and force
> bradycardia- rate less than 50 bpm
> tachycardia- rate greater than 90 bpm
> 3+ full, bounding; 2+ normal; 1+ weak, thready; 0 absent.
3) Respirations- for a neonate 30-40 breaths per min is normal; for an adult 10-20 is considered normal but 10 should be a concern.
4) Blood pressure- Can be checked in the arm or the thigh (brachial pulse, popliteal pulse)
> Normal: 120/80 or less
> Prehypertension: 120-139/80-89 JOUBERT/HAMMACK Page 1 NUR 3029: Health Assessment Final Exam: Study Guide
> Stage 1 hypertension: 140-159/90-99 > Stage 2 hypertension: >160/>100
Assessment of changes in BP (orthostatic BPS and nurse’s role)
> take serial measurements when you suspect volume depletion; when the person is known to have hypertension or is taking antihypertensive medication; or when the person reports fainting or syncope.
> have person rest supine for 2 to three minutes and take baseline readings of pulse and BP, and then repeat the measurements with the person sitting, then standing (for person too busy to stand, assess supine and then sitting with legs dangling. Normally when the position is changed from supine to standing, there is a slight decrease (les than 10 mmHg) in systolic pressure.
> orthostatic hypotension- drop in systolic pressure of more than 20 mmHg or orthostatic pulse increases in 20 bpm standing position.
> nurse must record the BP for each position, the arm used, and the cuff size if different from standard adult; also record the pulse rate and rhythm.
* If BP cuff is too narrow for the arm, it will result in a false high BP reading and if it is too loose or uneven it will result in a false low reading.
Pain Assessment and Vital Signs interpretation
>infants and children use the face pain scale
>PQRSTU
- Provocative/palliative
- Quality
- Region/Radiation
- Severity, 0-10
- Time
- Understands
* BP tends to be higher when a person is in acute pain ; in persons with chronic pain BP is not normally affected.
Integumentary Assessment Normal vs abnormal changes in the skin (infant, child, adult, older adults)
> test for skin turgor (tenting), which signifies dehydration- abdomen on infant, hand on an adult
> newborns nail beds may be cyanotic for the first few hours of life, then turn pink.
> adolescents experience acne; appear in children 7 to 8 years of age but usually peak at age 14 to 16 years in girls, and at 16 to 19 years in boys.
> skin for aging adult is much thinner
> acrochordons or “skin tags” occur frequently on eyelids, back, and axillae and trunk.
> hair growth decreases in aging adult and the amount of decrease in axillae and pubic areas. After menopause, women develop brisk hair on chin or upper lip; in men coarse terminal hairs develop in ears nose and eyebrows but beard is unchanged; male JOUBERT/HAMMACK Page 2 NUR 3029: Health Assessment Final Exam: Study Guide
pattern alopecia is a genetic trait (gradual receding in a symmetric W shape); in males and females, hair begins to change white due to loss of melanocyte function.
> with aging the nail growth rate decreases and surface may be brittle and sometimes yellowed; toe nails are thickened- make sure it is normal and not due to peripheral vascular disease
Abnormal skin and hair changes and descriptions
> pallor occurs with anemia, shock, arterial insufficiency, albinism (absence of melanin), and vitiligo (destruction of melanocytes)
> cyanosis in light skinned people- blue, in dark skinned- check conjuctiva, oral mucosa, and nail beds
> jaundice – yellow in sclera, hard palate, mucous membranes, skin; check palms
and soft palate in dark persons; light gray colored stool and dark golden urine.
> skin smooth with hyperthyroidism, skin dry in hypothyroidism
> in endocrine disorders cause excessive hair or hair loss
> tinea capitis- brittle scalp hair, dull, and coarse
> jagged nails- nervous picking habits; chronically dirty- poor self-care; clubbing
of nails occurs with congenital cyanotic heart disease and pulmonary disorders (nail is > 180 degrees with a spongy nail base)
> nails are thickened and rigid with arterial insufficiency
> alopecia- a condition in which hair is lost from some or all areas of the body, usually from the scalp.
> wheal- superficial, raised, transient, and erythematous; slightly irregular shaped due to edema; (ie. mosquito bite, allergic reaction; dermographism).
> bulla- larger than 1 cm diameter; usually single chambered; superficial in epidermis; thin walled so it ruptures easily; (ie. friction burn, dermatitis, burns).
> papules- solid, elevated, and circumscribed, less than 1 cm in diamete, caused by superficial thickening in the epidermis (ie. mole, wart).
> nodule- solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than a papule.
Changes in skin turgor and associated conditions > urticaria- “hives”; when wheals coalesce to form extensive reaction, intensely pruritic
> fissure- linear crack with abrupt edges, extends into the dermis, dry or moist. Ex: cheilosis- at corners of mouth due to excess moisture; athlete’s foot.
Head & Neck Sinuses
> using thumbs press the frontal sinuses by pressing up and under the eyebrows and over the maxillary sinuses below the cheekbones- person should feel firm pressure, but no tenderness/pain.
> Abnormal: person feels tenderness in presence of acute infection (sinusitis) or with chronic allergies
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Nasal passages-
> lift up the tip of the nose with finger before inserting otoscope head; view nasal cavities with the head erect and then with the head tilted back; Inspect he mucosa noting normal red color and smooth, moist surface.
> observe the septum for deviation- a deviated septum is common and not significant unless air flow is obstructed; also note any perforation or bleeding in the septum
> inspect the turbinates- the superior one will not be viewable, but the middle and inferior appear the same light red color as the nasal mucosa; turbinate’s are tender.
> Abnormal: Rhinitis- nasal mucosa is swollen and bright red; discharge is common with rhinitis and sinusitis, varying form watery to thick, purulent, and green-yellow; With chronic allergy, mucosa looks swollen, boggy, pale, and gray*; perforation is seen as a spot of light from a penlight shining in the
other naris and occurs with cocaine use; epistaxis- nose bleeding; polyps are smooth, pale gray, avascular,
mobile and nontender.
Oral mucosa- > The inside of the mouth looks pink, smooth, and moist, hard palate white with irregular transverse rugae and the posterior soft palate is pinker, smooth, and upwardly moveable; leukoedema- a benign milky bluish, white opaque areas- is normal.
> Abnormal: dappled brown patches are present with addisom’s disease; hard palate appears yellow with jaundice; oral Kaposi sarcoma is the most common early lesion in people with AIDS; candida
infection will usually rub off, leaving a raw denuded area; leukoplakia- chalky white raised patch; gums bleed with slight pressure indicating gingivitis
Thyroid gland
> is difficult to palpate; supply person with a glass of water and inspect the neck as the person takes a sip and swallows- thyroid tissue should move up.
> Thyroid posterior examination:
- to palpate behind, ask person to stand up straight and bend the neck and slightly to the left and then use your left hand to push the trachea slightly to the right. The right hand will then palpate between the trachea and the sternocleidomastoid muscle. Reverse the procedure for the left side. You should not be able to palpate the thyroid on a normal adult
> Thyroid anterior examination:
- alternate/best method of palpating thyroid. Stand facing the person ask him or her to tip
the head forward and to the right. This time use your right thumb to displace the trachea slightly to the person’s right. Next, hook the left thumb and fingers around the sternocleidomastoid muscle and feel for lobe enlargement when person swallows.
Assessment of the Throat
> uvula should be midline and when person says ah note the soft palate and uvula rise midline- tests one function of cranial nerve X, vagus.
> tonsils should be same color pink as oral mucosa and surface peppered with indentations or crypts; tonsils are graded as 1+ visible, 2+ halfway between tonsilar pillars and uvula, 3+ touching the uvula, 4+ touching each other- tonsils will be enlarged with acute infection
> touch the posterior wall with a tongue blade elicits a gag reflex. This tests cranial nerve IX and JOUBERT/HAMMACK Page 4
