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119 Cards in this Set
- Front
- Back
How long does a routine assessment take and when is it done?
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10-15 minutes, at beginning of each shift more frequently when a client's health status changes (sometimes done less often in nursing homes and home care setting)
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When does a nurse do a comprehensive assessment?
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When a patient is admitted to a health care facility
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5 basic assessment techniques
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inspection
palpation percussion auscultation olfaction |
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Inspection requires what 2 things
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good lighting and full exposure of selected body parts
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What must we look for when we are inspecting?
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size, shape, color, symmetry, position, presence of abnormalities. When possible, inspect each area compared with same area on opposite side of body
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Verify and clarify all abnormalities with _____ client data.
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Subjective
In other words, ask client for further information about each abnormality or change. |
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What does palpation detect?
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resistance, resilience, roughness, texture, temperature, mobility. Often used with or after visual inspection.
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The _____ of the hand is sensitive to temperature variations (palpation)
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dorsal side (back of hand)
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The ___ of the hand is especially sensitive to vibration
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palm
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The ______ of the _____ detect subtle changes in texture, shape, size, consistency, and pulsation of body parts.
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pads of fingertips
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The nurse measures ____, ____, and _____ by lightly grasping the body part with the fingertips.
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position, consistency, and turgor
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____ _____ during palpation impairs the ability to palpate correctly.
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Muscle tension
So help the client relax by asking him/her to take slow, deep breaths. |
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True or false: Palpate tender areas first.
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False, palpate tender areas last.
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Light palpation ____ deep palpation
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precedes
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How often should breast self-examinations should be done ?
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once per month
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For women who menstruate, the best time to do BSE is ___ or ____ days after a period endes, when the breasts are least likely to be tendon or swollen.
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2 or 3 days
(Women who no longer menstruate should just do BSE on same day every month, such as the first day.) |
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What sort of unusual changes should women look for in their skin during a BSE?
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discharge from nipples, puckering, dimpling, or scaling of skin
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The second part of the BSE should be done ___ ___ ____.
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In the shower. (Gliding fingers over soapy skin makes it easier to notice the texture underneath.)
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For the final steps of the BSE, the position is ____.
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lying down. This position flattens the breast and makes it easier to examine.
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During BSE, pay special attention to the area around the ____.
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armpit (and between breast & armpit)
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During BSE move from the ____ edge and press the flat part of your fingers around in small ____, moving slowly around the breast gradually working toward the nipple.
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outer, circles
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Men ____ years of age or older should perform a genital self-examination ______.
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15 years of age, monthly
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When should the genital exam be done?
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After a warm bath/shower when scrotal sac is relaxed
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In a penile examination, look for ....
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bumps, sores, blisters, bympy warts, discharge from penis
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Where should a man do a penile/testicular examination?
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In front of a mirror.
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What should he look for in a testicular examination?
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feel for lumps, thickening, or a change in consistency (hardening) . Do this by gently rolling testicle with thumb on top. Feel for small, pea-sized lumps on front and side of testicle, they are usually painless but are ABNORMAL.
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For light palpation, apply pressure slowly, gently and deliberately, depressing about ____ .
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1/2 inch or 1 cm
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Deeper palpation can be used to examine condition of organs. Depress the area being examined about _____.
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1 inch or 2 cm
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_____ palpation involves one hand placed over the other while applying pressure
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bimanual (the upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses.
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Seek assistance from your instructor before attempting ____ palpation.
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deep
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______ involves tapping the body with the fingertips to evaluate size, borders, and consistency of body organs and to discover fluid in body cavities. It identifies location, size, and density of underlying structures.
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Percussion
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To percuss, you strike the body's surface with a finger to create a _____. The character of sounds depends on the ____ of underlying tissues.
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vibration, density
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T or F: Percussion is easy.
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False. It requires practice and skill and is typically used by advanced practice nurses (APNs)
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4 characteristics of sound hear through auscultation
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frequency, loudness, quality, duration
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True or False: It is essential to place the stethoscope directly on client's skin because clothing obscures and changes sound.
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True
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______ uses the sense of smell to detect abnormalities that go unrecognized by other means.
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Olfaction
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The smell of ammonia in urine could indicate..
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UTI
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hyperhidrosis
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excessive perspiration
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bromhidrosis
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foul-smelling perspiration
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halitosis
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foul smelling breath
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the smell of a sweet, heavy,thick odor from a draining wound could indicate...
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pseudomonas (bacterial) infection
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the smell of stale urine on the skin could indicate...
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uremic acidosis
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the smell of sweet, fruity ketones in the oral cavity could indicate...
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diabetic acidosis
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Foul-smelling stool in infants could indicate...
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malabsorption syndrome
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A musty odor coming from a casted body part could indicate...
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infection inside cast
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A fetid, sweet odor from a tracheostomy or mucous secretions could indicate...
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infection of bronchial tree (pseudomonas bacteria)
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The smell of feces from a wound site could indicate...
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wound abscess
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The smell of alcohol from the oral cavity could indicate
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Hmm I wonder...
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The smell of feces in vomit (vomitus) could indicate...
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bowel obstruction
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the smell of feces in the rectal area could indicate...
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fecal incontinence
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Make sure you have a ____ ____ ____ ____ ____ ____ in room during assessment of genitalia
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third person of client's same gender
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For assessing ___________, focus on growth and development, sensory screening, dental examination, and behavioral assessment.
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children
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Call children by their ____ name and address adults/parents as "Mr./Mrs. Jones" etc.
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first
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True or false: Older children and adolescents respond better when treated as children.
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False, they are more responsive when treaetd as adults and individuals
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The adolescent has a right to _____.
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confidentiality
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For older adults, take advantage of natural opportunities for assessment such as ______, _____, and _____.
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bathing, grooming, mealtimes
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_______ an examination with older adults to keep position changes to a minimum. Be efficient throughout the examination to limit client movement.
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Sequence (throughly think through the order in which you will examine the individual)
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Make sure that an examination of an older adult includes a review of ____ _____.
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mental status
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Results have found that mammography screening for women age ___ years and older at least every ___ years was still favored as a method of breast cancer detection.
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age 40 and older, every 2 years
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True or false: Perform painful or intrusive procedures near the beginning of the exam.
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False: Near the end of the exam
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Follow the sequence of inspection, palpation, and auscultation thoruhgout the body except for in the _____ assessment.
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abdominal assessment in which we inspect, auscultate, and then palpate. (Palpation can alter or disrupt the auscultation.)
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True or False: In long term health care setting, arm bands (for identifying the patient) are not used.
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True. Pictures are available for identification
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Clients with difficulty hearing or an altered ____ may answer to a name other than their own.
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LOC
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Always wear gloves if there are _____, _____, or breaks in the skin. In some situations, you may need to wear a gown.
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lesions, wounds
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Record quick notes to facilitate____ documentation
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accurate
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Which culture/ethnic group is often:
highly tactile, very modest (men and women) may ask for health care provider of same gender, women may refuse to be examined by a male health care provider |
Hispanic
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Which culture/ethnic group is should we: avoid touching (patting head is strictly taboo), and touching during an argument equals loss of control (shame) and public display of affection toward members of same gender is ok just not opposite gender
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Asians/Pacific Islanders
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Which culture/ethnic group often:
does not like to be touched without permission, may exercise level of distrust or caution initially in health care provider |
African-Americans
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Which culture/ethnic group should we shake hands with lightly, and they don't like to be touched without permission. Nonverbal communication is very important.
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Native Americans
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Immobility, moisture from incontinence, inadequate nutrition, and circulatory alterations may cause/ influence a diagnosis of ____
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Impaired skin integrity or risk for impaired skin integrity
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Hypoventilation or hyperventilation along with influencing factors such as pain, anxiety, and decreased muscle strength/energy may indicate a diagnosis of ____
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ineffective breathing pattern
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______ pain is one of the most common symptoms found in hospitalized clients.
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abdominal
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Ineffective tissue perfusion involves a _____ deficit in blood supply to the _______ and is appropriate when finding reveal alteration in arterial or venous circulation.
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chronic, extremeties
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Disturbed thought process would be a nursing diagnosis if a client lacks ______ to time, person, and/or event or demonstrates an abnormality in any of the six components of the mental health examination.
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orientation
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The _____ _____ begins a review of the client's primary health problems and includes vital signs, height and weight general behavior, and appearance. It provides info about characteristics of an illness, a client's hygiene, skin and body image, emotional state, recent changes in weight, and developmental status.
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general survey
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If client has any acute signs of distress during a general survey, such as ____, ______, and ______, postpone general survey until later and focus immediately on body system affected.
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difficulty breathing, pain, anxiety
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When there is a language barrier, it is best to have an interpreter of the same _____ who is older and more mature. Translate ____ if possible.
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gender,
verbatim |
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1 liter of water weighs _____ kg or ____ lbs.
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1 kg or 2.2 pounds
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Weight of ___ to ___ % above standard indicates excess body fat. However, _____ _______ is one factor that must be ruled out.
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10 - 20%
fluid retention |
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Repeated exposure to latex gloves may result in serious reactions like ____, itching, and _______.
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asthma, itching, anaphylaxis
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Measuring height and weight, oral intake, urinary output, vital signs and reporting a client's subjective signs and symptoms may be delegated EXCEPT the ____ set or when client is ______
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EXCEPT the INITIAL set or when client is UNSTABLE
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In the general survey, take vital signs unless routinely taken within past ____ hours
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3
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Behavior may reflect specific ____ abnormalities. ____ and LOC influence ability to cooperate.
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physical, Dementia
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Timing of recent medications, especially _____ ______ and ______ may cause client to be groggy or less responsive.
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pain medication and sedatives
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In appropriate response from client may be caused by language ______, deterioration of mental ____, preocupation with _____ or decreased ______ acuity.
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barrier
status illness hearing |
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If a client knows his name, location, and situation, you can write " ________" in your documentation
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"Oriented x 3"
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_____ exists along a continuum that includes full responsiveness, inability to consciously initiate meaningful behaviors, and unresponsibeness to stimuli.
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LOC
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MMSE
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Mini-Mental State Examination, to be done when client has a questionable LOC. If drastic changes in mental status, notify physician.
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Evidence of abuse is often identified first by ____ _____ _____, because clients are often unable to tell family or friends.
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health care providers
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Signs of child sexual abuse
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blood on underclothing, pain in genital area, difficulty sitting or walking
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Main sign of abuse is injury or trauma that is _______ with reported _____
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inconsistent with reported cause
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______ interval between injury and time medical care was sought are signs indicative of older adult abuse or neglect.
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Prolonged
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___ injuries are left when an object with which a person is struch leaves an imprint
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Pattern
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_____ injuries such as bilateral bruises on upper arms suggest the person was held or shaken
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Parallel
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Melanoma is ___ times higher among whites than blacks.
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10 x
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______, (pinpoint red/purple spots on skin caused by small hemorrhages in skin layers) may indicate serious clotting disorder, drug reaction, or liver disease
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Petechiae
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Be alert for ____ cell carcinomas, such as an open sore that does not ____, shiny ______, a pink or reddish growth, or a scar-like area.
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Be alert for BASAL cell carcinomas, such as an open sore that does not HEAL, shiny NODULES, a pink or reddish growth, or a scar-like area.
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pneumonic rule for melanoma
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ABCD
Asymmetry of lesion Borders; irregular Color blue/black or varied Diameter greater than 6mm |
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What diameter is a cause of concern for possible malignant melanoma?
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> 6mm
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You can more easily identify abnormalities in the body where melanin production is ____. Look at color of face, oral mucosa, lips, conjunctivae, sclera, palms of hands, and nail beds.
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lowest
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What are some signs of impaired circulation?
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pallor, decreased temperature
Often caused by restraints, casts, bandages, etc. |
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Changes in ____ may be the first indication of skin rashed in dark-skinned clients
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texture
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signs of xerosis
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dry, scaly skin
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A ____ __ pressure ulcer may cause warmth and erythema (redness) of an area.
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Stage 1
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With altered skin ____ it is essential to provide measures for prevention of pressure ulcers
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turgor
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Peripheral cyanosis results from low ___ ___ or local _________.
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cardiac ouput, vasoconstriction
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Signs of petechiae in dark skin individual
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unsually invisible except in oral mucosa, conjunctivae, eyelids and covering of eyeballs
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_____ of the skin is related to decreased perfusion (blood flow, anemia, shock) . How is it different for darker skinned individuals?
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pallor. Ashen-gray appearance in black skin.
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How do you assess erythema in a light skinned vs. a dark skinned person?
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Light: redness easily apparent
Dark: Difficult to assess, palpate for warmth/edema |
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______ is relate to deposits of bilirubin in tissue and liver disease. In dark skinned individuals, it's reliably assessed in sclerae, hard palate, palms, and soles of feet. In light skinned individuals, it's a yellow staining in sclerae of eyes, skin, etc.
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jaundice
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How do we find ecchuymoses in dark skinned individuals?
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difficult to see except in mouth or conjunctivae
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Cyanosis is related to hopxia (late sign of decreased oxygen), heart/lung disease, cold environment. What changes will we see in light/dark skin individuals?
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Light: blue tinge especially in conjunctivae, nail beds, ear lobes, oral membranes, palms
Dark: ashen-gray lips, tongue |
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Description of ________ helps to indicate whether infection is present or the wound is healing
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secretions
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Areas at risk for pressure ulcers
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sacrum, greater trochanter, heels, occipital area, clavicles
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Normal reactive hyperemia (redness) is a visible effect of localized vasodilation, the body's normal response to lack of blood flow to underlying tissue. Except for in the case of a stage 1 pressure ulcer, affected area will ____ with fingertip pressure.
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blanch.
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If pressure on skin & bony prominence is not relieved, tissue damage can occur in as little as ____ minutes.
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90 minutes due to tissue hypoxia.
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hemoptysis
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bloody sputum
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ischemia
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inadequate tissue perfusion resulting in an inadequate delivery of oxygen and nutrients to cells. Results in pain.
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occlusion
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blockage
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