NUR 3029: Health Assessment Final Exam: Study Guide
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The comprehensive examination will contain 100 multiple questions. Please
... [Show More] 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 webbased 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 lessNUR 3029: Health Assessment Final Exam: Study Guide
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> Prehypertension: 120-139/80-89
> 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 andNUR 3029: Health Assessment Final Exam: Study Guide
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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
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 chronicNUR 3029: Health Assessment Final Exam: Study Guide
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allergies
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 midlinetests 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 thehat
occurs, it confirms the presence of a herniated nucleus pulposus. If lifting the unaffected leg reproduces
sciatic pain, it strongly suggests a herniated nucleus pulposus.
- Measure Leg Length Discrepancy: Perform this measurement if you need to determine
whether one leg is shorter than the other. For true leg length, measure between fixed points, from the
anterior iliac spine to the medial malleolus, crossing the medial side of the knee. Measurements are
normally equal or within 1 cm, indicating no true bine discrepancy. For apparent leg length, measure a
nonfixed point (the umbilicus) to a fixed point (medial malleolus) on each leg
- abnormal: Unequal leg lengths. True lengths are equal, but apparent lef lengths unequal- this
condition occurs with pelvic obliquity or adduction or flexion deformity in the hip.
Adolescents
- sit behind the child and ask the child to stand with the feet shoulder width apart and bend
forward slowly to touch the toes. Expect a straight vertical spine while standing and also while bending
forward. Posterior ribs should be symmetric, with equal elevation of scapula, shoulders, and iliac crests.
-Abnormal: scoliosis is most apparent during the preadolescent growth spurt. Asymmetry
suggests scoliosis- ribs hump up on one side as children bends forward and with unequal landmark
elevation;
- pregnant woman experiences postural changes including progressive lordosis and anterior
cervical flexion.
Range of Motion
active (voluntary) ROM- a patient can actively (without assistance) move a joint using the adjacent
muscles.
passive motion- if person is limited, attempt passive motion with the persons muscles relaxed and with
you moving the body parts; always anchor the joint with one hand while your other hand slowly moves it
to its limit. The normal ranges of active and passive should be the same.
> abnormal: limitation in ROM is the most sensitive sign of join disease; articular disease
produces swelling and tenderness around the whole joint and limits all planes of ROM in both active and
passive (extra-auricular- to a certain/specific spot in the joint); crepitation is an audible and palpable
crunching or grating that accompanies movement, as with rheumatoid arthritis.
Muscle Strength Testing
> test the strength of the prime mover muscle groups for each join. Ask person to flex and hold as you
apply opposing force.
> muscle strength should be equal bilaterally and should fully resist opposing forces.
> arm strength: stabilize persons arm with one hand have the person flex the elbow against your
resistance applied just proximal to the wrist. Ask the person to extend the elbow against resistance.
> wrist strength: position the person’s forearm supinated and resting on a table. Stabilize by holding your
hand at the persons midforearms and ask the person to flex the wrist against your resistance
> leg strength: ask person to maintain knee flexion while you oppose trying to pull the leg forward.
Muscle extension is demonstrated by the persons success in rising from a seated position in a low chair or
by rising from a squat without using hands for assistance.NUR 3029: Health Assessment Final Exam: Study Guide
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Aging adult
> loss of bone resorption occurs more rapidly than new bone formation after age 40, which leads to a loss
of bone density or osteoporosis
> women have a greater degree of osteoporosis than men because 5 years after menopause, the lack of
estrogen leads to accelerated bone loss
> decreased height and postural changing is seen with aging due to shortening of the vertebral columnbegins at age 40 in males and 43 in females but not significant until 60 years; lengthening of the armtrunk axis.
> postural changes such as kyphosis with a slight flexion of hips and knees.
> lose fat in hips and face and deposit it in abdomen and hips.
> bony prominences more marked (tips of vertebrae, ribs, iliac crest) and body hollows deeper (cheeks,
axillae).
> absolute loss in muscle mass occurs and atrophy and weakness
**physical exercise increases skeletal mass and helps prevent or delay osteoporosis- fast walking is the
best prevention.
> for those with advanced aging changes, arthritic changes or musculoskeletal disability, perform a
functional assessment for ADLs- tests safety of independent living (walk, climb upstairs, walk down
stairs, pick up object from floor, rise up from a seating chair, and rise up from lying in bed).
> person walks with shuffling pattern with arms out for balance; person holds onto hand rails and may
haul body up with it; person holds hand rails walking downstairs (both); person bends at the waist instead
of bending the knees and holds onto furniture to support; persons uses arms to push of the chair arms,
upper trunk leans forward, and feet are planted wide; to get up from lying down aged person may roll to
one side and push with arms to lift torso and grab beside table.
Female and Male Client Assessment
Self Breast Examination teaching- finish own assessment then teach self-examination so you can focus on
the examination and to avoid diversion and also so patient is relaxed when you educate; Best time to
conduct BSE is right after the menstrual period, or the 4th through 7th day of the menstrual cycle, when the
breast are smallest and least congested; Advise a pregnant or menopausal woman who is not having
periods to select a familiar day to examine her breasts each month ie. birthday; emphasize the absence of
bumps, rather than the presence; Give facts such as, the majority of women will never get it, the majority
of breast lumps are benign, and if caught early survival rate is 98%
** When obtaining sexual history and assessing the patient it is important to as the patient about
menstrual cycle before sexual history to make the patient feel more comfortable.
Male assessment
> testicular examination
- inspect the scrotum as the male holds the penis out of the way; asymmetry is normal,
with left scrotal half usually lower than the right
- spread rugae out between your fingers, lift the sac to inspect the posterior surface (may
find sebaceous cysts that are yellowish, 1-cm nodules firm and nontender).
- palpate gently each scrotal half between your thumb and first two fingers firm and
rubbery, smooth, and equal bilaterally and freely movable and slightly tender to moderate pressureNUR 3029: Health Assessment Final Exam: Study Guide
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Abnormal: scrotal swelling (edema) may occur with heart failure or renal failure; absent testis
may be a temporary migration or true cryptorchidism (testes that have never de; atrophied testis are small
and soft; fixed; nodules on testes or epididymides; marked tenderness; varicocele- torsion
> prostate examination- on the anterior wall of the male is the bulging prostate gland. Palpate
the entire prostate in a systemic manner but note that only the superior and part of the lateral surfaces are
accessible to examination; press into the gland at each location to check for nodules; surface should feel
smooth and muscular (size: 2.5 cm long 4 cm wide, elastic rubbery, slightly movable, nontender to
palpation, smooth, and heart shaped)- if abnormal it would feel large, flat, firm, tender, fixed, nodular,
etc.
Teaching about self examination with males
> TSE: encourage self-care by teaching males from 13 to 14 years old through adulthood how to
examine his own testicles; testicular cancer is rare before the age of 15 years, peaks during ages 20 to 39,
and then declines; testicular cancer has no early symptoms but if detected early before metastasis, the cure
rate is 100%; stress familiarity of male’s own body rather than only cancer detection as the goal. Points to
include during health teaching are T= timing, once a month, S= shower, warm water relaxes scrotal sac,
and E= examination, check for changes, report changes immediately.
External Genitalia(Vulva)
Mons pubis
Labia majoral (rounded folds of adipose tissue)
Labia mijora
Clitoris
Perineum: between vaginal opening and rectum
Urethra opening can be positioned above or below
Examining External Genitalia
Should have assistance by an aid or another nurse (required for male nurses)
Ensure patient wears a gown
Wear gloves throughout examination
Patient; place 1 heal at a time in the foot rests; thigh flexed & abducted at the hips; arms folded across
chest; butt at edge of table
Explain each step of the procedure; check patients face for discomfort
Tanner chart: explains sexual maturity*
Check for swelling, bruising, check their inguinal lymph nodes (palpate)
Internal Genitalia Anatomy
Examining Internal Genitalia
Separate labia and tell patient to bare down
Inspect perineal area: palpate for tenderness
Anal area: see if any hemorrhoids
*Do not use gel lubricant
Normal cervical discharge: odorless, clear to white or thick to thin
Cervical broom used to get specimens from inner and outer cervix
*To describe lesions; ex 2 o’clock at vaginal canal
Use 2 fingers to check vaginaNUR 3029: Health Assessment Final Exam: Study Guide
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Palpate right and left ovaries
Rectovaginal Exam
Able to feel behind the cervix
Patient may feel like they are going to have a bowel movement
Rectovagino fistula: passage way; tissue breaks down & forms new passage way; feces comin out of
urethra
Anus And Rectum Exam
*Occult blood: nonvisible in rectum (hemacult test; hidden blood would turn blue)
*Overt blood is visible in rectum
o Bright red: hemmoroids, etc
o Dark blood: higher in GI tract
Describe Your Findings
Describe visible tissue
Find any lesions: locate geographically
*Nurses don’t do internal exams
Anatomy Of Male Genitalia And Hernias
Patient can be standing or supine
*In males, stds and less symptomatic
Shaft has 3 columns of tissue
Glands is hairless end of penis
Left scrotum is usually lower
Hernias: small intestine floats around and finds an opening in wall of abdomen
o Scrotal hernia: small intestine falls into hernia; from internal indirect inguinal hernia
o Umbilical hernias
o Inguinal canal hernias
o Femoral canal hernias
Examining Male Genitalia
Inspect glans, any lesions or scars
Compress glands to open urethral meatus
Note any discharge
Palpate shaft of penis; should be no tenderness
Assessing For Hernias
Inspect areas of inguinal canal and femoral canals
Increase abdominal pressure: ask patient to squat as if they have bowel movement
Ask patient to cough to see if there is a bulging mass in
Anatomy Of Rectum
Anal canal is sensitive to pain
Seminal vessicles are usually not palpable
Urgency to pee, not much peeing out: prostate problemsNUR 3029: Health Assessment Final Exam: Study Guide
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Examining Anus, Rectum, And Prostate Gland
Position patient on left side
Right leg should be flexed
Hemorrhoids can be external or internal
Lubricate index finger to put finger into rectum; tell them to relax and bare down
Is fecal matter is present, test for occult blood
Describe Your Findings
No discharge or lesions noted [Show Less]