NURS 6512: Advanced Health Assessment Midterm Exam Review (2024/2025), Exams of Nursing

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NURS 6512: ADVANCED HEALTH ASSESSMENT. WEEK 6

LATEST MIDTERM EXAM 202 4 /202 5 AND REVIEW.

QUESTIONS WITH 100% CORRECT ANSWERS.

CHAMBERLAIN UNIVERSITY. GRADED A+

QUESTIONS

1. Before performing an abdominal examination, the examiner should: Have the patient empty their bladder
2. During an interview, tears appear in the patient’s eyes and his voice becomes shaky. Initially, you should: Keep the interview moving to distract the patient
3. Which of the following is the most accurate reflection of an individual’s food intake? Food Diary
4. Percussing at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating the: Lower liver border
5. A fixed image of any group that rejects its potential for originality or individuality is known as a: Stereotype
6. Peritonitis produces bowel sounds that are Decreased/Hypoactive
7. Brittle nails are typical findings in: Older adults
8. Which of the following is an expected change in the assessment of the thyroid during pregnancy? A Bruit is auscultated d/t increased vascularity
9. You are planning to palpate the abdomen of your patient. Which part of the examiner's hand is best for palpating vibration? Ulnar Surface
10. A 5 - year-old child presents with nasal congestion and a headache to assess for sinus tenderness you should palpate over the: Maxillary sinuses only

11. During physical examination of a 30 - year-old Chinese man you notice a slight asymmetry of his face. the cranial nerve examination is normal. Your best action is to Ask the patient if this characteristic runs in his family
12. Unusual white areas on the skin may be due to Vitiligo
13. You are using an ophthalmoscope to examine a patient’s inner eye. You rotate the lens selector clockwise, then counterclockwise to compensate for: Myopia
14. Mrs. Webb is a 38 - year old patient who has been changing her lifestyle to eat in a healthy way and lose weight: during your health promotion education regarding her nutritional status, you explain the function of dietary protein as: Building and maintaining tissues
15. Mr. Akins is a 78 - y/o patient who presents to the clinic with complaints of hearing loss. Which of the following are changes in hearing that occur in the elderly? Select all that apply. c. Loss of high frequency e. Sounds may be garbled, difficult to localize f. Unable to hear in a crowded room
16. The most superior part of the stomach is the Fundus
17. Mrs. Grace is a 58 - year-old patient who has a diagnosis of pernicious anemia. Which B vitamin is deficient in patients with pernicious anemia? B
18. A 51-y/o woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to: Come to the laboratory for a stool guaiac test.
19. Placing the base of a vibrating tuning fork on the midline vertex of the patient’s head is a test for: Lateralization of Sound
20. Which technique is most likely to result in the patients understanding of questions? Use the patient's own terms if possible.
21. Mr. Williams, age 25, has recovered recently from an upper and lower respiratory infection. He describes a long-standing nasal dripping. He is seeking treatment for a mild hearing loss that has not gone away. Information concerning his chronic postnasal drip should be documented within which section of the history? Past medical data
22. Nasal symptoms that imply an allergic response include: Bluish gray turbinates. ("Turbinates that appear bluish gray or pale pink with a swollen, boggy consistency may indicate allergies"-Seidel p.243)
23. Mr. Franklin is speaking with you the health care provider, about his respiratory problem. Mr. Franklin says, “I’ve had this cough for 3 days and it’s getting worse.” You reply, “Tell me more about

your cough.” Mr. Franklin states, “I wish I could tell you more, that’s why I am here! You tell me what’s wrong.” Which caregiver response would be the most appropriate for enhancing communication? After 3 days, you're tired of coughing. Have you had a fever?"

24. When taking a history, you should: Use a chronologic and sequential framework.
25. Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)? Brief SOAP note
26. Mr. and Mrs. Johnson have presented to the office with their infant son with complaints of ear drainage. When examining an infant’s middle ear, the nurse should use one hand to stabilize the otoscope against the head while using the other hand to: Pull the auricle down and back in an effort to straighten the upward curvature of the canal
27. Mr. Black is a 44y/o patient who presents to the clinic with complaints of neck pain that he thinks is from his job involving computer data entry. As the examiner, you are checking the range of motion in his neck and note the greatest degree of cervical mobility is at? C 4 to C 5: C4 and C5 or C5 and C 6 provide the greatest horizontal mobility in adults
28. The term denoting the caregiver’s need to do no harm to the patient is: Deontologic imperatives.
29. A tool used to screen adolescents for alcoholism is the: CRAFFT
30. Under normal circumstances, how much water is lost daily by the body? Under normal circumstances, approximately 2 to 2.5 liters of water is lost daily
31. You have just completed a skin assessment on Mr. Baker. During your assessment, you have transilluminated a skin lesion. During the physical examination, you know that skin lesions are transilluminated to distinguish: Transillumination is used to determine the presence of fluid in cysts and masses. Fluid-filled lesions will transilluminate with a red glow, and solid masses will not transilluminate.
32. Mr. Mills is a 55/y/o patient who presents to the office for an initial visit for health promotion. A survey of mobility and activities of activities of daily living is part of a(n): Functional assessment.
33. Sweat glands, hair, and nails are all formed from? Invagination of epidermis into dermis
34. A brief statement of the reason the patient is seeking health care is called the? Chief concern
35. Which part of the information contained in the patient’s record may be used in court?

Anything that is entered into a patient’s record in paper or electronic form, is a legal document and can be used

36. Which cranial nerves innervate the face? 5 and 7
37. In counseling a client regarding nutrition education, you explain that linoleic acid, a major fatty acid, is thought to be essential for? Linoleic acid, found abundantly in milk and dairy fat, is required for normal growth and development, it has been suggested that it can reduce body fat in overweight patient
38. When are open-ended questions generally most useful? During the initial part of the interview
39. Knowledge of the culture or cultures represented by the patient should be used to? Help make interview questions more pertinent 40. Mrs. Berger is a 39 - year-old woman who presents with a complaint of epigastric abdominal pain. You have completed the inspection of the abdomen. What is your next step in the assessment process? Auscultation
40. A guideline for history taking is for caregivers to? Make notes sparingly so that patients can be observed during the history taking
41. Which type of speculum should be used to examine a patient’s tympanic membrane? The largest speculum that will fit comfortably in ear
42. You are palpating a patient’s thyroid and find that its broadest dimension measures 4cm. the right lobe is 25% larger than the left. These data would indicate? The description is most likely a normal finding
43. Mr. L. presents to the clinic with severe groin pain and a history of kidney stones. Mr. L.’s son tells you that, for religious reasons, his father wishes to keep any stone that is passed into the urine filter that he has been using. What is your most appropriate response? Healthcare provider should be willing to modify delivery and respectful of wishes/culture background
44. Before performing an abdominal examination, the examiner should? Have the patient empty his or her bladder
45. You are examining a pregnant patient and have noted a vascular lesion. When you Blanche over the vascular lesion, the site blanches and refills evenly from the center outward. The nurse documents this lesion as a? Telangiectasia
46. As you explain your patient’s condition to her husband, you notice that he is leaning toward you and pointedly blinking his eyes. Knowing that he is from England, your most appropriate response to this behavior is to? The English worry about being overheard and tend to speak in a modulated voice, so when they lean toward you, they probably have a question
47. When palpating the abdomen, you should note whether the liver is enlarged in the?

The liver is located in the right upper quadrant of the abdomen

49. Expected normal percussion tones include? Normal lings produce renaissance percussion tones
50. Mr. Abdul is a 40 - year-old Middle Eastern man who presents to the office for a first visit with the complaint of new abdominal pain. You ate concerned about violating a cultural prohibition when you prepare to do his rectal examination. The best tactic would be to? Inform the patient of the reason for the exam and ask if it is acceptable to him
51. Fluorescing lesions are best distinguished using a(n)? Wood’s lamp
52. Mrs. Hartzell is a 34 - year-old patient who has presented for nutritional counseling because she is a vegetarian. Deficiency of which of the following is a concern in the vegetarian diet? Proteins, calcium, iron, B12, and vitamin D
53. Underestimation of blood pressure will occur if the blood pressure cuff’s width covers? Cuff that are too wide will underestimate blood pressure, which would happen with a cuff that is more than one third of the upper arm
54. Mrs. Britton is a 34 - year-old patient who presents to the office with complaints of skin rashes. You have noted a 4’3cm, rough, elevated area of psoriasis. This is an example of a? Plaque
55. Penicillin is considered a? Miracle drug for all the reasons except. It was not the first antibiotic.
56. Small, minute bruises are called? Petechiae
57. After thorough inspection of the abdomen, the next assessment step is? Auscultation
58. When you are questioning a patient regarding alcohol intake, she tells you that she is only a social drinker. Which initial response is appropriate? What amount and what kind of alcohol do you drink in a week?
59. Regardless of the origin, discharge is described by noting? Color and consistency
60. Recommended carbohydrate content of total dietary intake (% total calories) is? 50%
61. Tuning forks with a frequency of 500 to 1000 Hz are most commonly used to measure? Hearing range of normal speech
62. Auscultation should be carried out last, except when examining the? The abdomen

63. Mr. Kevin Marks is a new health care provider. What is the best method to develop cultural competence? Realize the cultural values are difficult to change and must be respected
64. Which of the following is an “ABCD” characteristic of malignant melanoma? Asymmetric borders
65. Tracheal tug suggests the presence of a(n)? Aortic aneurysm
66. Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition early in its course? Consistent right lower quadrant pain
67. The review of systems is a component of the: Personal and social history
68. Cherry angiomas are a common finding in: Adults older than 30 years
69. Mr. Donalds is a 45 - year-old roofer. Your inspection to determine color variations of the skin is best conducted: with illumination provided by daylight.
70. To correctly document absent bowel sounds, one must listen continuously for: 5 minutes
71. The adult recommended dietary fat intake should be g/day. 20 to 35
72. Mr. Jones is a 45 - year-old patient who presents for a physical examination. On examination, you note costochondral beading, enlarged skull, and bowed legs and diagnose him with rickets. A deficiency of which fat-soluble micronutrient can result in rickets? Vitamin D
73. A flat, non-palpable lesion is described as a macule if the diameter is: Less than 1 cm
74. Mrs. Raymonds is a 24-year-old patient who has presented for a routine concern over her current weight. In your patient teaching with her, you explain the importance of macronutrients. Which of the following is a macronutrient? Fat
75. Which of the following organs is part of the alimentary tract? continuous tract from the mouth to the esophagus, stomach, small intestine, large intestine, and anus
76. Mr. Sanchez is a 45 - year-old gentleman who has presented to the office for a physical examination to establish a new primary care health care provider. Which of the following describes a physical, not a cultural, differentiator? Race

77. To approximate vocal frequencies, which tuning fork should be used to assess hearing? 500 to 1000 Hz
78. During percussion, a dull tone is expected to be heard over: The liver
79. The attitudes of the health care professional: Culturally derived/are largely irrelevant to the success of relationships with the patient
80. When recording physical findings, which data are recorded first for all systems? Inspection
81. Spasmodic muscular contractions of the head, face, or neck are called: tics
82. Which of the following occurs when firm pressure is used to apply the stethoscope’s bell end-piece to the skin? It functionally converts to a diaphragm end-piece.
83. Differential diagnoses belong in the: Assessment
84. Pigmented, raised, warty lesions over the face and trunk should be assessed by an experienced practitioner who can distinguish: seborrheic keratoses from actinic keratoses.
85. Mr. Walter’s, a 32 - year-old patient, tells you that his ears are “stopped up.” An objective assessment of this complaint is achieved by using the: tympanometer
86. Mrs. Leonard brings her newborn infant into the pediatrician’s office for a first well-baby visit. As the health care provider, you teach her that newborns are more vulnerable to hypothermia due to: a poorly developed subcutaneous fat layer.
87. Tympanic thermometers measure body temperature when a probe is placed: Eardrum (in the ear)
88. A serous membrane that lines the abdominal cavity and forms a protective cover for many abdominal structures is the: peritoneum
89. White, rounded, or oval ulcerations surrounded by a red halo and found on the oral mucosa are: aphthous ulcers (canker sores)
90. When assessing abdominal pain in a college-age woman, one must include: the first day of the last menstrual period.
91. Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to:

inspect for ecchymosis of the flank.

92. The infant should be placed in which position to have his or her height or length measured? Supine on a measuring board 93. Mr. Marks is a 66-year-old patient who presents for a physical examination to the clinic. Which question has the most potential for exploring a patient’s cultural beliefs related to a health problem? "Why do you think you are having these symptoms?"
93. Which of the following is the most vital nutrient? water
94. What finding is unique to the documentation of a physical examination of an infant? Fontanel size
95. Mrs. G. reports an increase in her alcohol intake over the past 5 years. To screen her for problem drinking, you would use the: CAGE questionnaire
96. Mr. D. complains of a headache. During the history he mentions his use of alcohol and illicit drugs. This information would most likely belong in the: personal and social history
97. You are completing a general physical examination on Mr. Rock, a 39 - year-old man with complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient: flex his or her knees
98. When communicating with older children and teenagers, you should be sensitive to their: typical reluctance to talk
99. Periods of silence during the interview can serve important purposes, such as: Providing time for reflection. Question 11 2 out of 2 points Which technique is commonly used to elicit tenderness arising from the liver, gallbladder, or kidneys? Response Feedback: The fist percussion is a direct percussion technique used to elicit tenderness over organs such as the liver, gallbladder, or kidneys.

• Question 12 2 out of 2 points A rubber or plastic ring should be around the bell end-piece of a stethoscope to: Response Feedback: The ring around the bell portion of the stethoscope functions to secure contact with body surfaces when placed lightly on the skin.
• Question 13 2 out of 2 points In terms of cultural communication differences, Americans are more likely to than are other groups of patients.

Response Feedback: In the United States, individuals are very direct in conversation and come to the point quickly. They also tend to talk more loudly and to worry less about being overheard.

• Question 14 2 out of 2 points For a woman with a small vaginal opening, the examiner should use a speculum. Response Feedback: The Pederson speculum has blades that are as long as those of the Graves speculum but are both narrower and flatter and therefore more comfortable for women with small vaginal openings. Pediatric or nasal speculums would be too small for adult use. Plastic speculums are similar in uses to the metal counterparts.
• Question 15 2 out of 2 points During percussion, the downward snap of the striking fingers should originate from the: Response Feedback: The dominant hand s middle finger strikes the stationary finger with a wrist motion and is lifted quickly off the striking surface.
• Question 16 2 out of 2 points You are auscultating a patient s chest. The sounds are not clear, and you are having difficulty distinguishing between respirations and heartbeats. What technique can you use to facilitate your assessment? Response Feedback If you are hearing everything at once, it is more difficult to distinguish different sounds. Try isolating each segment and: listen to that segment intently, then move on to another segment. For example, listen only to breath sounds, then only to inspiratory breath sounds, then only expiratory breath sounds.
  • Question 17 2 out of 2 points Expected normal percussion tones include: Response Feedback: A normal lung produces resonance percussion tones while an empty stomach is expected to produce tympany. Dull percussion tones are heard over the liver.
• Question 18 2 out of 2 points During auscultation, you can limit your perceptual field best by: Response Feedback: By closing your eyes, your sense of hearing becomes more acute and it increases your ability to isolate sounds.
• Question 19 2 out of 2 points Standard Precautions apply to all patients: Response Feedback: Although all of the statements are true, the best answer is 4. Want

NURS 6512

Midterm Exam Review (Weeks 1 - 6)

Building A Complete Health History

1. Communication techniques used to obtain a patient’s health history o Courtesy ▪ Knock before entering a room ▪ Address (first time) the patient formerly, such as Miss, Ms., Mrs. Mr. – can shake their hand(s) ▪ Meet and acknowledge others in the room. Establish their role and degree of participation ▪ Learn their names ▪ Ensure confidentiality ▪ Give them your undivided attention – take some time – don’t rush out ▪ Take minimal notes – use keywords. Observe and listen ▪ Respect the need for modesty ▪ Allow the patient time to change back into street clothes before resuming conversation o Comfort ▪ Ensure everyone is comfortable (including yourself) ▪ Maintain close, but comfortable proximity with patient ▪ Maintain privacy. Pull curtains and shades as applicable ▪ Ensure comfortable room temperature. Provide blanket if needed ▪ Ensure good lighting ▪ Ensure quiet surrounding ▪ Pace interview. If necessary, prioritize and complete at another visit o Connection ▪ Look at patient, maintain good eye contact (if culture allows) ▪ Watch your language (don’t use technical jargon & don’t patronize)

▪ Don’t dominate the discussion (listen closely & allow patient to prioritize issues) ▪ Keep an open mind – don’t accept previous diagnosis as a chief complaint ▪ Inquire if patient turned away from another provider to come to you ▪ Take history and complete physical exam before looking at previous tests

• Consider first what the patient has to say ▪ Avoid leading or direct questions in the beginning
• Use open-ended questions.
• Let the specifics evolve ▪ Avoid being judgmental ▪ Respect silence – pauses can be productive ▪ Be flexible ▪ Assess the patient’s potential as a partner in their care ▪ Seek clues to problems from patient’s verbal behavior and body language (talking too fast or too little) ▪ Look for hidden concerns underlying chief concern ▪ Never trivialize any finding or clue ▪ Problems can have multiple causes – do not leap to one cause too quickly ▪ Define any concern completely: LOCATES, OLDCARTS o Confirmation ▪ Ask patient to summarize the discussion (should be a clear understanding) ▪ Allow the possibility of more discussion with another open-ended question (“Anything else you would like to bring up?”) ▪ If there is a question that you cannot immediately answer – say so & follow up later if possible ▪ If you have made a mistake, make every effort to repair it.
• Candor is important for the development of a trusting partnership. ▪ Most patients respect it.

2. Recording and documenting patient information o Illustrations – sometimes can be a better description o POMR – problem oriented medical record ▪ Comprehensive health history

• Chronological order

• HPI - OLDCARTS

▪ Complete physical examination ▪ Problem list ▪ Assessment/plan ▪ Baseline & problem directed labs/radiology ▪ Progress notes

3. SOAP note documentation o Subjective data ▪ Told to you by patient o Objective data ▪ What you see o Assessment ▪ Interpretations/conclusion – rational ▪ Diagnostic strategy ▪ Present and anticipated problems ▪ Ongoing and future care o Plan ▪ What you intend to do ▪ Specific for each problem ▪ Includes: diagnostics/therapeutics/patient education
4. Subjective vs objective information when documenting o Subjective – information from the individual’s point of view (symptoms); may include feelings, perceptions, and concerns o Objective – observable and measurable information obtained through observation, physical examination, and laboratory and diagnostic testing
5. Ethical decision making and beneficence o Beneficence – promoting/doing good Diversity and Health Assessments
6. Cultural awareness and diversity o Culture – reflects the whole of human behavior, including ideas and attitudes; ways of relating to one another; manners of speaking; and the material products of physical effort, ingenuity, and imagination o Physical characteristics – gender, race, phenotypic traits o Minimize stereotyping and prejudice to achieve cultural competence o Cultural competence – Knowledge of cultural encounters, desire, awareness, knowledge, and skill o For ethnic minorities, assess social context through inquiry of stressors, support networks, sense of life control, and literacy o Be sensitive to a patient’s heritage, sexual orientation, socioeconomic status, ethnicity, and cultural background

7. Socioeconomic, spiritual, and lifestyle factors affecting diverse populations o Disease is shaped by illness and illness is shaped by the totality of the patient’s experience o Definition of ill or sick is based on the patient’s belief system and is determined by their enculturation
8. Functional assessments o Beliefs and behaviors that will have an impact on patient assessment include: ▪ Mode of communication – speech, body language, space - In the US, people talk more loudly while the English worry about being overheard and are more modulated - In US – people are direct in conversation and prefer to avoid the subject and to come to the point quickly while the Japanese do the opposite, using indirection and talking around points, and emphasizing attitudes and feelings - Silence allows those who are Native American to think and a response should not be forced; allow for quiet time - Firm eye contact is evident in the Spanish and French while Asian and Middle Eastern cultures believe it is a sign of disrespect. ▪ Health beliefs and practices that may vary from your own - Naturalistic or holistic approach believes that external factors must be kept in balance to remain well - Balance of hot and cold is a belief of Asians, Middle Eastern, Hispanics, and Native Americans - Treat condition with the opposite to restore balance ▪ Diet and nutritional practices - Orthodox Jewish will not take some medicines, particularly during holiday period like Passover - Muslims must respect Halal - Chinese patient with HTN and salt-restricted diet may need to limit MSG and soy sauce - Dietary supplements containing ephedra alkaloids mat increase risk of stroke, whereas other herbal preparations interact with prescribed medicines ▪ The nature of relationships within a family - Be aware of the sequence of related behaviors because it may be unrelated to the integrity of the family structure, gender, or background - Parenting style of child-rearing practices like setting boundaries and expectations may be culturally driven

Assessment Tools and Diagnostic Tests in Adults and Children

9. Growth, Development, and Measurements in children and adults General o Growth Hormone: stimulates the pituitary to release the growth hormone. o Somatostatin inhibits the secretions of the growth hormone and thyroid stimulating hormone. o Growth hormone promotes growth, increase in organ size, regulates car, protein and lipid metabolism. o Thyroid hormone stimulates growth hormone secretion and production of insulin like growth factor-plays an important role in bone formation and resorption. o 70% of growth occurs during sleep. o At 34 weeks gestation, 65% of the weight of the newborns brain is present. o By 3 years old, most brain growth is complete. o Lymphatic tissues: reach adult size at age 6, double at 10 - 12 years of age, then decrease back to adult size during adolescence. Infants and Children o Legs are the fastest growing body part during childhood. o Fat tissue increases slowly until 7 years old, then pre-pubertal fat spurt occurs before the true growth spurt. o In adolescence, 50% of the individual weight is gain, and skeletal mass and organ sytm double in size. o Sexual Maturation in girls: early 7, late 12 o Sexual Maturation in boys: early 9, late 14 Older adults o Physical stature declines beginning at age 50. o Age 60 and over will have a decrease in weight for height and BMI, and approximately 5% body weight loss over several years. o Older adults will see an increase in body fat, and skeletal muscle loss due to decrease in exercise. o May see a decrease in size and weight of organs such as liver, kidney, lung. o In the last 15 years, there has been an increase in obese older adults. Pregnant Adults o Fetus accounts for 6 - 8 pounds of total weight gained, the other is due to an increase in maternal tissues. ▪ Fluid volume: 2- 3 pounds ▪ Blood volume: 3- 4 pounds ▪ Breast enlargement: 1 - 2 pounds ▪ Uterine enlargement: 2 pounds ▪ Amniotic fluid: 2 pounds ▪ Maternal fat and protein stores: 4 - 6 pounds o Weight gain slow during first trimester, rapid during second and third, fetal growth accounts for most weight gained during third trimester o Inadequate weight gain=increased risk for low birth weight infant

BMI

o Most common method used to assess nutritional status and total body fat. ▪ Undernutrition: less than 18. ▪ Appropriate: 18.5-24. ▪ Overweight: 25 - 29. ▪ Obese: 30 - 39. ▪ Extreme obesity: 40 and higher Infant Measurements o Health baby length: 18 - 22 inches o Weigh the baby to the nearest 10 g o Average variations in birth weight (5lbs 8oz to 8lbs 13oz) =2500-4000g o Infants double their birth weight by 4 - 5months and triple by 12 months o Head circumference: measure nearest 0.5cm or ¼ inch; wrap tape around occipital protuberance and the supraorbital prominence o Normal newborn head circumference: 32.5-37.5 cm o Chest circumference: used when problem is suspected; measure midway between inspiration and expiration to the nearest 0.5cm or ¼ inch; wrap at nipple line; at 5mths-2 years the chest and head are close to same size, and after 2 years, the chest exceeds the head circumference.

10. Nutritional assessment to include recommended water intake and energy requirements o Assess the patient’s nutritional status including: ▪ Recent growth, weight loss, weight gain ▪ Chronic illnesses ▪ Medication and supplement ▪ Nutrition screen ▪ Assessment of nutrition intake o Water : most vital nutrient, body is approximately 55 - 65% water ▪ Functions as: providing turgor, altering dissolved substances, transporting dissolved nutrients and waste, maintaining stable temperature. ▪ Approximately 2 - 2.5 liters are lost daily. o Energy requirements : includes used at rest, energy used in physical activity, and energy used as a result of thermogenesis. Affecting these are: age, gender, body size, composition, genetics and physiologic state, disease and temperature.
11. Macronutrients vs Micronutrients Macronutrients o Includes: carbohydrates, protein and fat ▪ Carbohydrate: main source of energy (4 calories/ gram)

• Serve major functions in vital organs: liver, heart, central nervous system
• Recommended daily intake: 45-65% of total calories (130g = adults) ▪ Protein major functions: build and maintain tissue, regulate water and acid base balance, precursor for enzymes, antibodies and hormones ( calories/gram)
• Recommended protein intake of diet 10 - 35% of total calories (46g women, 56 g men) ▪ Fat: memory storage, energy metabolism, absorption of fat-soluble vitamins. (9 calories/gram)
• Recommended fat intake of diet 20 - 35% of total calories Micronutrients o Vitamins, minerals, electrolytes

12. Significance of a food diary o Provides a retrospective view of an individual’s eating habits and dietary intake, recorded as it happened o Collects relevant data that may aid in identifying problem areas
13. BMI measurements for normal, overweight, obesity, morbid obesity o Normal – 18.5 to 24. o Overweight – 25 to 29. o Obesity – 30 to 39. o Morbid obesity – 40 and higher
14. Pernicious Anemia o B12 deficiency is usually the result of impaired B12 uptake caused by lack of intrinsic factor that is caused by a loss of parietal cells in the stomach lining. o The loss of these cells can be caused by partial or full gastrectomy, Crohn’s disease, autoimmune disorders such as DMI and immunocompromised disease such as HIV. o A smooth red tongue with a slick appearance may indicate NIACIN or Vitamin B12 deficiency.
15. Examination techniques and equipment o Inspection – used throughout physical exam and interview process o Palpation – gathering information through touch o Auscultation – carried out last except when examining kidney or abdomen. Used to listen to sounds produced by the body

o Fist – use for indirect finger percussion by striking the middle finger of the nondominant hand o Deep abdominal palpation of the kidney used to assess tenderness over the kidney. o Ulnar surface of the hand used to palpate mass in the skin o Dorsal surface of the hand – sensitive to vibration o Percussion Tone expected ▪ Stomach – tympanic ▪ Sternum – flat ▪ Liver – dull ▪ Lung of a patient with pneumonia – dull ▪ Abdomen with lung tumor – Dull

16. Diagnostic Assessment tools and tests to include tuning forks, BP monitoring, use of stethoscope, otoscope, ophthalmoscope o Weight scales and height measurement devices – always observe what patient is wearing and calibrate the scale each time to ensure accuracy o Thermometer – tympanic thermometers are best in children ages 2 months to 16 years; infrared axillary thermometers for neonates o Stethoscope – for auscultation; three basic types are acoustic (most common), magnetic, and electronic o Sphygmomanometer – manual BP requires stethoscope and sphygmomanometer; electronic sphygmomanometer also available (no stethoscope required) and works by sensing vibrations and converting them into electric impulses o Pulse oximeter – measures the percentage of hemoglobin saturated with oxygen (oxyhemoglobin); adult/pediatric sites are finger, toes, pinna (top) or lobe of the ear; infant sites are the foot, palm of the hand, big toe, or thumb o Doppler – should be used when there is difficulty auscultating with regular stethoscope; they are ultrasonic stethoscopes that detect blood flow; used to detect systolic BPs, auscultate fetal heart activity, locate vessels, take weak pulses, assess vessel patency, localize acute and chronic arterial occlusions, assess DVTs and valvular incompetency, and assess testicular torsion and varicocele o Portable ultrasound – ultrasound waves pass through fluids and soft tissue; helpful in assessing fluid-filled organs (bladder) and soft organs (gallbladder and liver); shows the structure and movement of organs, blood flow through vessels, and abnormalities (cysts, tumors, and infections); aids in clinical procedures (pleural effusions, abscesses, and biopsies)

o Fetal monitoring equipment – fetal heart rate determined by using fetoscope and Leff scope, a stethoscope, or an electronic instrument that uses doppler o Ophthalmoscope – enables visualization of the interior structures of the eye; numbers on the instrument correspond to the magnification power o PanOptic Ophthalmoscope – uses and optical design that allows a large field of view o StrabismoScope – used for detecting strabismus (eye misalignment) and can be used as part of eye testing in children o Photoscreening – used to detect amblyopia (lazy eye) and strabismus in children through the use of camera or video to obtain images of pupillary reflexes and red reflexes o Visual acuity charts – Snellen Alphabet (screening exam of far vision for literate, verbal, and English-speaking adults and school-aged children), Tumbling E (nonalphabet version of Snellen chart; has the letter “E” facing in different directions), HOTV (wall chart composed only of H’s, O’s, T’s, and V’s; child must match the letter on the wall chart to the testing board), LEA Symbols (consists of four optotypes – circle, square, apple, house – that blur equally and child must match), and lastly Broken Wheel Cards (picture cards where child must identify the cards with broken wheels on the car) o Near vision charts – can use a designed chart (Rosenbaum or Jaeger) or simply newsprint o Amsler grid – used to test those at risk for macular degeneration o Otoscope – provides illumination for examining the external auditory canal and tympanic membrane; can also be used for nasal examination o Tympanometer – simple and reliable way of assessing the functions of the ossiscular chain, eustachian tube, and tympanic membrane o Nasal speculum – used with a penlight to visualize the lower and middle turbinates of the nose o Tuning fork – used in screening tests for auditory function and for vibratory sensation as part of the neuro exam o Percussion (reflex hammer) – used to test deep tendon reflexes o Neurologic hammer – variant of the reflex hammer; also used for testing deep tendon reflexes o Tape measure – used for determining circumference, length, and diameter o Transilluminator – consists of a strong light source with a narrow beam; beam is directed to a body cavity to determine media present in the cavity (fluid in the sinuses or blood in the scrotum)

o Vaginal speculum – two blades and a handle; three types (Graves, Pederson, and Pediatric/Virginal) o Goniometer – used to determine the degree of joint flexion and extensions o Wood’s Lamp – contains a light source that aids in determining the presence of fungi on skin lesions o Dermatoscope – a skin surface microscope that uses epiluminescence microscopy (ELM) to illuminate and magnify a skin lesion to allow for a more detailed inspection o Calipers for Skinfold Thickness – measure the thickness of subcutaneous tissue at certain points of the body o Monofilament – designed to test for loss of protective sensation, particularly on the plantar surface of the foot o Scoliometer – measures the degree of rotation of the spine to screen for scoliosis Assessment of the Skin, Hair, and Nails

17. Skin lesion characteristics o Skin lesion – general term that collectively describes any pathologic skin change or occurrence ▪ May be primary or secondary o Lesions should be described according to characteristics, exudates, configuration, and location and distribution ▪ Macule – flat, circumscribed area that is a change in the color of the skin; <1 cm in diameter (freckles, measles, petechiae, flat moles) ▪ Papule – elevated, firm, circumscribed area; <1 cm in diameter (wart, elevate mole) ▪ Patch – flat, nonpalpable, irregularly-shaped macule >1 cm in diameter (vitiligo, Mongolian spots, port-wine stains) ▪ Plaque – elevated, firm, and rough lesion with flat top surface >1 cm in diameter (psoriasis, actinic keratoses) ▪ Wheat – elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter (insect bites, urticaria, allergic reaction) ▪ Nodule – elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1 - 2 cm in diameter (erythema nodosum, lipoma) ▪ Tumor – elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; >2 cm in diameter (neoplasms, benign tumor, lipoma) ▪ Vesicle – elevated, circumscribed, superficial, not into dermis; filled with serous fluid; <1 cm in diameter (varicella, herpes zoster) ▪ Bulla – vesicle >1 cm in diameter (blister) ▪ Pustule – elevated, superficial lesion; similar to a vesicle but filled with purulent fluid (impetigo, acne)

▪ Cyst – elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material (sebaceous cyst, cystic acne) ▪ Telangiectasia – fine, irregular, red line produced by capillary dilation (rosacea) ▪ Scale – heaped-up, keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size (flaking of skin from dermatitis or drug reaction; dry skin) ▪ Lichenification – rough, thicken epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surfaces of extremity (chronic dermatitis) ▪ Keloid – irregularly shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing (keloid formation following surgery) ▪ Scar – thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis (heated wound or surgical incision) ▪ Excoriation – loss of the epidermis; linear hollowed-out, crusted area (abrasion or scratch, scabies) ▪ Fissure – linear crack or break from the epidermis to the dermis; may be moist or dry (athlete’s foot, cracks at the corner of mouth) ▪ Erosion – loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla (varicella, variola after rupture) ▪ Ulcer – loss of epidermis and dermis; concave; varies in size (decubiti, stasis ulcers) ▪ Crust – dried serum, blood, or purulent exudates; slightly elevated; size varies; brown, red, black, tan, or straw-colored (scab on abrasion, eczema) ▪ Atrophy – thinning of skin surface and los of skin markings; skin translucent and paper-like (striae, aged skin)

18. Documenting skin lesions using “ABCD” rule o To document changes in moles o A – asymmetry o B – border o C – color o D – diameter
19. Anatomy and physiology of skin layers o Epidermis ▪ Outermost portion of skin ▪ Two layers: - Stratum corneum – protects body against harmful environmental substances & restricts water loss o Closely packed, dead squamous cells that contain keratin – form the protective barriers - Cellular stratum – where keratin cells are synthesized o Stratum germinativum (deepest layer of cellular stratum) – where keratin cells are formed; also contains melanocytes

o Stratum lucidum – present only in thicker skin (palms & soles) ▪ Avascular and depends on dermis for nutrition o Dermis ▪ Richly vascular connective tissue layer of skin that supports and separates the epidermis from the cutaneous adipose tissue ▪ Elastin, collagen, reticulum fibers, sensory nerve fibers, and autonomic motor nerves o Hypodermis ▪ Subcutaneous layer that consists of loose connective tissue filled with fatty cells ▪ Generates heat & provides insulation, shock absorption, & a reserve of calories o Appendages ▪ Epidermis invaginates into the dermis at various points to form appendages:

• Eccrine sweat glands, apocrine sweat glands, sebaceous glands, hair, and nails

20. Abnormal nail findings in older adults o Nail growth slows because of decreased peripheral circulation. The nails, particularly the toenails, become thicker, brittle, hard and yellowish. They develop longitudinal ridges and are prone to splitting into layers.
21. Psoriatic skin lesions o Multifactorial origin with genetic component and immune regulation. Characterized by increased epidermal cells turnover, increased number of epidermal stem cells, and abnormal differentiation of keratin expression leading to thickened skin with copious scale. o May have puritis o Well-circumscribed, dry silvery, scaling papules and plaques o Lesions commonly occur in the back, buttocks, extensor surfaces of the extremities, and the scalp. o Can be associated with psoriatic arthritis in up to 30% of patients.
22. Vesicular skin characteristics o Elevated, circumscribed, superficial, not into dermis o Filled with serous fluid, less than 1cm in diameter – chicken pox, shingles o Vesicle greater than 1cm is called a bullae – blister, pemphigus vulgaris
23. Normal vs abnormal hair distribution during aging o Normal: ▪ Adolescent – increase in hair oiliness; hair on the extremities darkens and becomes coarser; pubic and axillary hair in both males and females develops and assumes adult characteristics; males develop facial and chest hair that varies in quantity and coarseness ▪ Pregnant women – hair growth is altered during pregnancy due to circulating hormones; the growing phase of their hair is lengthened, and

hair loss is decreased; 2 - 4 months after delivery increased hair shedding occurs; regrowth of hair occurs 6- 12 months ▪ Older adults – hair turns gray or white as melanocytes cease functioning; head, body, pubic, and axillary hair thins and becomes sparse and drier; men may show an increase in coarse aural, nasal, and eyebrow hair; women tend to develop coarse facial hair; symmetric balding (usually frontal or occipital) often occurs in men o Abnormal: ▪ Bald spots in children and infants – typically ringworm of the scalp (tinea capitis, alopecia areata, or trichotillomania (compulsive hair-pulling); infants who sleep on their backs can develop areas of alopecia from pressure of occiput ▪ Alopecia areata – sudden, rapid, patchy loss of hair (usually from the scalp or face); unknown cause ▪ Scarring alopecia – replacement of hair follicles with scar tissue; causes by skin disorders of the scalp or follicles that result in scarring ▪ Traction alopecia – hair loss that is the result of prolonged, tightly pulled hairstyles; follicle is not damaged, and the loss is reversible ▪ Hirsutism – growth of terminal hair in women in the male distribution pattern on the face, body, and pubic areas; caused by high androgen levels or hair follicles that are more sensitive to normal androgen levels

24. Characteristics of hair distribution o Like much of the hair on the human body, leg, arm, chest, and back hair begin as vellus hair. As people age, the hair in these regions will often begin to grow darker and more abundantly. This will typically happen during or after puberty ▪ Men – abundant, coarser hair on the arms and back ▪ Women – less drastic change in hair growth in arms and back but have significant change in thickness of hairs o Chest and Abdomen ▪ Vellus hair grows on the chest and abdomen of both sexes at all stages of development ▪ Puberty to adulthood – males grow increasing amounts of terminal hair over the chest and abdomen areas - Women can grow terminal hairs around areola o Arms ▪ Grows on forearms ▪ Terminal arm hair – concentrated on the wrist end of the forearm, extending over the hand - Males – much more intense than in females (especially with dark hair) ▪ Vellus arm hair – seen on elbow end of the forearm and ends on the lower part of the upper arm

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• Women – looks hairy but it is softer and different compared to men’s arm hai

▪ Visible hair on the top surfaces of feet and toes that begins with the onset of puberty ▪ More intense in adult and adolescent males than in females o Legs ▪ Appears at the onset of adulthood, with legs of men more often hairier than those of women o Pubic ▪ Collection of coarse hair found in the pubic region, thighs, and abdomen ▪ Thick pubic hair acts as a cushion during intercourse ▪ The gential area of males and females are first inhabited by shorter, lighter vellus hairs that are next to invisible and only begin to develop into darker, thicker pubic hair at puberty o Armpits ▪ Underarm hair starts at the beginning of puberty and ends during the teenage years ▪ Thin fine hairs o Facial ▪ Grows around one’s face ▪ Non-vellus facial hair will begin to grow around puberty

• Men – facial hair begins to grow around the age of puberty, although some men may not grow a moustache until they reach late teens or not at all
• Women – develop a few facial hairs under or around the chin, along the sides of the face (in the area of sideburns), or on the upper lip.

25. Normal assessment findings of an adolescent’s nose and throat (Same as Adult) o Nasal mucosa should glisten and appear deep pink o A film of clear discharge is often apparent on the nasal septum ▪ Purulent drainage may indicate: respiratory infection, sinusitis, or foreign body o Hairs may be present in the vestibule. o Turbinates are parallel curbed bony structures covered by vascular mucous membrane that form the lateral walls of the nose and protrude into the nasal cavity. They increase the nasal surface area to warm, humidify, and filter the air. ▪ Inferior meatus drains the nasolacrimal duct, the medial meatus drains the paranasal sinus, and the superior meatus drains the posterior ethmoid sinus. ▪ They are firm and the same color as the surrounding area. ▪ Turbinates with bluish-gray or pale pink with a swollen, boggy consistency may indicate allergies ▪ Rounded, elongated masses projecting into the nasal cavity from the boggy mucosa may be a polyp o Nasal septum close to midline and fairly straight with the anterior septum thicker than the posterior septum

▪ Deviation may be indicated by the asymmetric size of the posterior nasal cavities o Sense of smell (CN1) tested with different odors. o Sinuses: Only the maxillary and frontal sinuses are accessible for physical examination