An instructor is teaching a group of students about culture. How would the instructor define the term to students? Experienced by all people even without human contact.Shared system of values, beliefs, and learned patterns of behaviorTransmission to another generation through geneticsAdapted to a specific environmentNUR 323 – Health Assessment & Health Promotion
Exam 4 – Study Guide (Final)
Exam 4 will consist of 75 questions from the following information from your textbook:
• Box 11-1: Terms and Definition Related to Culture
o Acculturation—The circumstance when a person gives up the traits of his or
her culture of origin as a result of context with another culture, to variable
o Assimilation—The gradual adoption and incorporation of characteristics of the
o Cultural diversity—The co-existence of a difference in behavior, traditions,
and customs—in short, a diversity of cultures, often resulting from cross-border
population flows; perhaps better referred to as “cultural pluralism”
o Cultural imposition—The intrusive application of the majority group’s cultural
view upon individuals and families
o Cultural relativism—The belief that the behaviors and practices of people
should be judged only from the context of their cultural system.
o Culture—The totality of socially transmitted behavioral patterns, arts, beliefs,
values, customs, lifeways, and all other products of human work and thought
characteristic of a population or people that guide their worldview and decision
o Enculturation—A natural conscious and unconscious conditioning process of
learning accepted cultural norms, values, and roles in society and achieving
competence in one’s culture through socialization.
o Ethnicity—A socially, culturally, and politically constructed group that holds in
common a set of characteristics not shared by others with whom members of the
group come into contact
o Ethnocentrism—The universal tendency of humans to think their ways of
thinking, acting, and believing are the only right, proper, and natural ways.
o Stereotyping—An oversimplified conception, opinion, or belief about some
aspect of an individual or group.
o Subculture—A group of people with a culture that differentiates them from the
larger culture of which they are a part.
o Worldview—The way individuals or groups of people look at the universe to
form basic assumptions and values about their lives and the world around them;
includes cosmology, relationships with nature, moral and ethical reasoning,
social relationships, major religious beliefs, and aesthetics.
• Table 11-1: Cultural Variations of Traditional Healers and Practices
▪ Chinese medical practitioners, herbalist
Prevent or rebalance yin/yang, hot/cold foods and conditions, wear
amulets, acupuncture, cupping, moxibustion
▪ Magical herbalist, Hoodoo (aka conjurers), “old lady,” “granny” or lay,
▪ Magical and herbal mix of herbs, roots, and rituals, talismans or amulets
o Native (American/Alaska, Native traditions)
▪ Medicine men or shamans
▪ Respect for nature and avoid spirits, use masks, herbs, sand paintings,
▪ Folk healers
▪ Hot/cold balance for diet, herbs, amulets, prayers to God and saint and
spiritual reparations for sins, avoiding “evil eye” caused by jealousy and
o Western European
▪ Homeopathic physicians, physicians, and other health professionals
▪ Maintain physical and emotional well-being with proper science-based
modern nutrition, exercise, cleanliness, belief in and faith in God
o Culturally based
o Tone and voice can make or break a conversation
o Nonverbal communication is most often misinterpreted variations
▪ Gestures, silence, touch, eye contact, body language
o Time is to be measurable (western cultures) or fluid and flowing (eastern
o Focused on the past value practices that are unchanged from those of ancestors
and are often resistant to new ways.
o Those focused on the present perceived what is happening in the present to be
more important than what will occur in the future.
o Those who are future oriented place value on deferring pleasure for a later gain.
o We each wear a zone of privacy
o Asians and Americans tend to keep more space btw them when speaking. Latins,
stay closer to each other and middle easterners move in the closest
Diet and Nutrition
o What we eat, when we eat and how we eat is all culture based
o Meaning of food to the individual, common foods eaten and rituals surrounding
the eating, distribution of food, religious beliefs about foods, beliefs about food
and health promotion, and nutritional deficiencies associated with the ethnic
o Compare nutrients of foods with nutrition charts to compare to regard to diseases
o Food serves as comfort or as a means to stay close to ethnic roots or family
o Providing food can reflect caring and love, while withdrawing food may be
considered akin to torture.
o When serving meals is important because if a person eats at a certain time serving
differently can be unappetizing
o Religious beliefs affect what can or cannot be eaten, such as prohibition of pork
or pork products for Jews and Muslims and religious practices of fasting.
o Asking about specific requirements or preferences is part of culture assessment.
Purpose and Scope of Assessment
o To be culturally competent and interact with client showing respect for the
person, family, and beliefs
o To learn about beliefs and usual behaviors associated with health and illness
o Compare and contrast clients beliefs and practices to standard western health care
o Compare the clients beliefs and practices with other persons from similar cultural
backgrounds (avoid stereotyping)
o To assess clients health relative to diseases prevalent in specific cultures
Concepts and Terms Related to Culture
o Culture bound syndromes: condition that are perceived to exist in various cultures
and occur as a combination of psychiatric or psychological and physical
▪ Much debate about folk illnesses with behavior changes, local variations
of western psych disorders, or whether they are not syndromes at all but
local ways of explaining negative events in life
▪ Clients perceive the syndromes to be conditions with specific symptoms.
It’s important to acknowledge the clients beliefs that symptoms for a
disorder even if western medicine calls it something else or not as a
▪ Based on different beliefs about what causes disease
o Culture based treatments are often misinterpreted in western health care settings
as they frequently produce marks on the skin interpreted as abuse
o Most Asian treatments are cupping, coining and moxibustion
▪ Cupping used to treat back pain, involves placing heated glass jars on skin.
Cooling causes suction that leave redness and bruising.
▪ Coining involves rubbing ointment into the skin with a spoon or coin.. it
leaves bruises or red marks but doesn’t cause pain. Used for “wind illness”
(fear of being cold or of wind, which causes loss of yang), fever, and
stress-related illnesses such as headache.
▪ Moxibustion is the attachment of smoldering herbs to the end of
acupuncture needles or the placement of the herbs on the skin; this causes
scars that look like cigarette burns. Used to strengthen ones blood and the
flow of energy and maintain good health
▪ In native American culture, medicine is about healing the person rather
than curing the disease. All based on spiritual elements and herbal
remedies including teas, tinctures, and salves. Common remedy for pain
uses bark from a willow tree which contains acetylsalicylic acid known in
o Imbalance in hot/cold is believed to cause disease, so treatment would be to take
foods, drinks or medication of the opposite type (hot for a cold and cold for a hot
condition). Cancer, headache, and pneumonia are described as cod, whereas
diabetes mellitus, hypertension and sore throat or infection are hot
o Difference in Western Vs Latino treatment is pregnancy is a hot condition; iron
containing foods are also hot, this pregnant female should not eat iron containing
o In Asian societies, hot/ cold is associated with the body’s energy of yin/yang
which must remain in balance for health. Yin/ Yang balance is maintained
through diet, lifestyle, acupuncture and herbs
o Counseling or psychiatric treatment are resisted by some Asians and many other
cultures because psychological or psychiatric illness is shameful
Pregnancy and Childbearing
o Include sanctioned and unsanctioned fertility practices
o Varies across cultures
o Beliefs about conception, pregnancy and childbearing are passed from generations
• Table 12-1: Major World Religions and Common Health Records
▪ Overview: Suffering is a part of human existence. Death leads to a state
beyond suffering and existence
▪ Illness: Prayer and meditation are used for cleansing, and healing.
Terminal illness may be seen as way to reflect on life’s ultimate meaning
and meaning of ones relation with the world. Meditation shouldn’t
interfere with consciousness
▪ Death: Life is opportunity to cultivate understanding, compassion, and joy
for self and others. Death is associated with rebirth. Serene surroundings
are important to the dignity of dying
▪ Nutrition: strict vegetarians. Holy days include fasting from dawn to dust
with considerations to frail and elder.
▪ Overview: nirvana (oneness with god) is the primary purpose of the
religion. Many have alter in home for worship
▪ Illness: result of past and current life actions (karma) the right hand is seen
as holy and eating and intervention (IV) needs to be with the right hand to
promote clean healing.
▪ Death: marks a passage b/c the soul has no beginning or end. At death the
soul may be reborn as another person and ones karma is carried forward. It
is important for karma to leave this life with as little negativity to ensure
better reborn life. Holy water and basil leaves may be placed on the body;
sacred threads may be tied around wrist or neck. Deceased arms should be
▪ Nutrition: many are vegetarians. Holy days include fasting
▪ Overview: Mohammed is believed to be the greatest prophets. Worship
occurs in a mosque. Prayer occurs five times a day: dawn through sunrise,
noon, afternoon, sunset and evening. Prayers are done facing east toward
the sacred place in mecca and often occur on a prayer rug with a ritual
washing of hands, face, and feet prior to prayer. Women are the most “
modest” and are not to view men, other than their husbands, naked. The
Islamic faith is presently one of the fastest growing religions in the US
▪ Illness: often believed to be a trial sent by god, and the outcome depends
on the persons attitude of pious endurance. Allah is in control of the
beginning and end of life and expression of powerlessness are rare. To
question or ask questions of healthcare provider is considered a sign of
mistrust, thus clients and family are less likely to ask
▪ Death: all outcomes of death or healing are seen as predetermined by
Allah. It is important for dying clients to face east and to die facing east.
Prayer is offered but not be done by an imam (religious leader).
▪ Nutrition: consumption of pork or alcohol is prohibited. Other meats must
meet ritual requirements and many use kosher (Jewish ritual) foods
because these meet the requirements of Islamic believers as well. During
the holy days of Ramadan (29 days determined by the moon), neither food
or drink is taken between sunrise and sunset, though frail, ill and young
▪ Beliefs focus around the old and new testaments of the bible and view
Jesus Christ as the savior. Prayers may be directed to one or all of the holy
trinity (god, holy spirit, and Jesus Christ). Beliefs usually culturally
developed vary within denominations.
▪ Illness: natural process for the body and even as a testing of faith. Others
may see it as a curse brought by living outside the laws of god and
therefore retribution for personal evil.
▪ Death: belief in miracles, especially through prayer. Western medicine is
usually held in high regard. Memorial services rather than funerals and
cremation rather than burial are more common.
▪ Nutrition: no special or universal food beliefs.
▪ Overview: Religious beliefs and a philosophy for a code of ethics with
four major groupings of Jewish beliefs, reform, reconstructionist,
conservative, and orthodox. Prayer shawls are common and are often
passed btw generations. A member of the clergy is known as a Rabbi.
▪ Illness: restrictions related to work on holy days are removed to save a
life. Tests, signatures, and assessments for medical needs that can be
scheduled to avoid holy days are appreciated.
▪ Death: psalms and the last prayer of confession (vidui) are held at bedside.
At death, arms are not crossed; any clothing or bandages with clients
blood should be prepared for burial with the person. It is important that the
whole person be buried together.
▪ Nutrition: orthodox or kosher rules involve no mixing of meat with dairy;
separate cooking and eating utensils are used for food preparation and
consumption. Kosher laws include special procedures for slaughter and
food handling. “ keeping kosher” is predominantly and orthodox practice.
when food has passed kosher laws of preparation, a symbol (k) appears on
the label. Holy days include a fasting period.
Impact of Religion and Spirituality on Health
o Potential to encourage greater mental and physical health
o Can express a variety of values and practices, including rituals and ways of
dealing with health care needs and end of life care
o Can guide conversations and decisions about referrals or collaboration
o Refusing of care ex: Jehovah witnesses refuse blood transfusions
o Views on modern health and western medicine
o Religion can lead to depression or anxiety due to not meeting expectations
Assessment Tool 12-1: Taking a Spiritual History: SPIRIT Acronym
o S: Spiritual belief system
▪ Do you have a formal religious affiliation?
▪ Can you describe it? Do you have a spiritual life that is important to you?
What is your clearest sense of the meaning of your life at this time?
o P: Personal spirituality
▪ Describe the beliefs and practices of your religion that you personally
▪ Describe those beliefs and practices that you do not accept or follow.
▪ In what ways is your spirituality/religion meaningful for you?
▪ How is your spirituality/religion important to you in daily life?
o I: Integration with a spiritual community
▪ Do you belong to any religious or spiritual groups or communities?
▪ How do you participate in this group/community? What is your role?
▪ What importance does this group have for you?
▪ In what ways is this group a source of support for you?
▪ What types of support and help does or could this group provide for you
in dealing with health issues?
o R: Ritual practices and restrictions
▪ What specific practices do you carry out as part of your religious and
spiritual life (e.g., prayer, meditation, services, etc.)?
▪ What lifestyle activities or practices does your religion encourage,
discourage, or forbid?
▪ What meaning does these practices and restrictions have for you? To
what extent have you followed these guidelines?
o I: Implications for medical care
▪ Are there specific elements of medical care that your religion
discourages or forbids? To what extent have you followed these
▪ What aspects of your religion/spirituality would you like me to keep in
mind as I care for you?
▪ What knowledge or understanding would strengthen our relationship as
physician and patient?
▪ Are there barriers to our relationship based on religious or spiritual
Would you like to discuss religious or spiritual implications of health
o T: Terminal events planning
▪ Are there particular aspects of medical care that you wish to forgo or
have withheld because of your religion/spirituality?
▪ Are there religious or spiritual practices or rituals that you would like to
have available in the hospital or at home?
▪ Are there religious or spiritual practices that you wish to plan for
regarding time of death, or the period following death?
▪ From what sources do you draw strength in order to cope with this
▪ For what in your life do you still feel gratitude even though ill?
▪ When you are afraid or in pain, how do you find comfort?
▪ As we plan for your medical care near the end of life, in what ways will
your religion and spirituality influence your decisions?
Assessment Tool 12-5: FICA Spiritual History Tool
o F—Faith and Belief
▪ “Do you consider yourself spiritual or religious?” or “Is spirituality
something important to you” or “Do you have spiritual beliefs that help
you cope with stress/ difficult times?” (Contextualize to reason for visit
if it is not the routine history.)
▪ If the patient responds “No,” the health care provider might ask, “What
gives your life meaning?” Sometimes patients respond with answers
such as family, career, or nature.
▪ (The question of meaning should also be asked even if people answer
yes to spirituality.)
▪ “What importance does your spirituality have in your life? Has your
spirituality influenced how you take care of yourself, your health? Does
your spirituality influence you in your health care decision making (e.g.,
advance directives, treatment, etc.)?
▪ “Are you part of a spiritual community? Communities such as churches,
temples, and mosques, or a group of like-minded friends, family, or yoga
can serve as strong support systems for some patients. Can explore
further: Is this of support to you and how? Is there a group of people you
really love or who are important to you?”
o A—Address in Care
▪ “How would you like me, your health care provider, to address these
issues in your health care?” (With the newer models, including diagnosis
of spiritual distress, A also refers to the Assessment and Plan of patient
spiritual distress or issues within a treatment or care plan.)
▪ Explore pts religious and spiritual background: asking if they associate
with any religions and if so how it relates to health care decisions.
▪ Observe nonverbal and verbal communication patterns. Use spirit
assessment tools and begin conversations with general dialogue such as
hope, meaning, comfort, strength, love, peace, and connection. Eye
contact is key. Ask about religious groups or insolvents. Inquire about
family/ community support, personal beliefs, do you believe in god or
higher power, any religious practices or rituals.
• History of Present Health Concerns
o Other symptoms
▪ Burning or itching indicates allergies or superficial irritation. Throbbing,
stabbing or deep, aching pain suggest foreign body in eye or changes in
▪ Redness or swelling of eye usually related to inflammatory response
caused by allergy, foreign body, bacterial or virus
▪ Excessive tearing (epiphora) caused by exposure to irritants or obstruction
of the lacrimal apparatus. Unilateral epiphora is often associated with
foreign body or obstruction. Bilateral epiphora is associated with exposure
to irritants, such as makeup or facial cleansers or a systemic response.
▪ Discharge can indicate bacteria or viral infection
• Assessment Procedures
o Testing Extraocular Muscle Function
▪ Cardinal field of gaze test for CN 3, CN 4, CN 6
• “H” pattern
• Wagon wheel test
• Accommodation test
▪ Corneal light reflex test
▪ Cover eye test
o Evaluating Vision
▪ Ophthalmoscope allows to view fundus of the eye with light
▪ Distance visual acuity with Snellen chart
▪ Near visual acuity with jaeger reading card
▪ Gross peripheral vision
• Assessment Guide 16-1 Vision Charts
o Snellen chart: used to test distant visual acuity
▪ 20/20 vision
o E chart: used to test distant visual acuity in pts with verbal communication
▪ Pt points to the direction of the way the “E” opens
o Jaeger test: near vision test for pts over 40yrs old
▪ Pts who have decreased accommodation to view close print will have to
move card further away to see it
• Abnormal Findings 16.6 – Abnormalities of the Optic Disc
• Abnormal Findings 16.3 – Abnormalities of the External Eye
• History of Present Health Concern
o Other symptoms
▪ Drainage (otorrhea) indicates infection. Purulent, bloody
▪ Earache (otalgia) indicates ear infections, cerumen blockage, sinus
infections, or teeth and gum problems
▪ Swimmers ear; middle ear infections
▪ Ringing in the ear (tinnitus) indicates earwax buildup, high BP, certain
ototoxic meds, loud noises
▪ Vertigo (true spinning motion), indicates inner ear problems
o Changes in Hearing
▪ Sudden decrease in ability to hear in one ear indicates otitis media or
▪ Presbycusis often starts with loss of high-frequency (women’s voice) to
low frequency loss
• Assessment Guide 17.1 – Otoscope
o Flashlight type viewer used to visualize eardrum and external ear canal
o Lift up and pull back auricle to see in ear canal
• Assessment Procedure
o General Observations of Hearing and Equilibrium Tests
▪ Whisper test: able to correctly repeat two-syllable words whispered
▪ Weber test: vibrations heard equally well in both ears. No lateralization
of sounds to either ear
▪ Rinne test: air conduction is normally heard longer then bond conduction
▪ Romberg test: client maintains standing position with eyes closed 20
seconds without swaying or with minimal swaying
▪ Bilaterally symmetrical
▪ Auricle matches with corner of eye
▪ Smooth, no lesions, lumps or nodules
▪ Auricle, tragus, mastoid process non tender
▪ Normal cerumen (earwax)
• Evidence-Based Health promotion and Disease Prevention: Lung Cancer (19-2)
o Must know the following:
• Leading cause of deaths in US
• More men than women, blacks than whites
• Age is a factor; 82% 60yrs and older
▪ Risk Assessment
• Smoking and second hand smoke
• Asbestos or radon
• Arsenic, diesel, silica, chromium
• Beta-carotene supplements
▪ Client Education
• Seek medical assessment for respiratory symptoms
• Quit smoking
• Use PPE if work in risk area
• Have home or office checked for asbestos etc
o Posterior Thorax
• Scapulae are symmetric non protruding and equal
• Ratio of anteroposterior to transverse diameter is 1:2
• Spinous process appear straight, thorax symmetric, ribs slopping
downward at 45 degree angle
• No accessory muscles needed for breathing
• Pt sitting upright and relaxed. (Not in tripod position; emphysema)
Respiration Patterns (Table 19-3)
▪ > 24 shallow
▪ Normal for fever, anxiety, exercise
▪ Can occur in respiratory insufficiency, alkalosis, pneumonia and pleurisy
▪ < 10 ▪ Normal in athletes ▪ Can occur with medication-induced depression, diabetic coma, neuro damage o Hyperventilation ▪ Increased rate and increased depth ▪ Occurs in extreme exercise, fear, anxiety ▪ Causes: CNS disorders, overdose, drug salicylate, severe anxiety o Kussmaul ▪ Rapid, deep, labored ▪ Associated with diabetic ketoacidosis o Hypoventilation ▪ Decreased rate, decreased depth, irregular pattern ▪ Associated with overdose of narcotics or anesthetics o Cheyne-stokes ▪ Regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea ▪ Result from CHF, drug overdose, increased cranial pressure, renal failure. May be associated with elders during sleep not related to disease process o Biot respiration ▪ Irregular patter characterized by varying depth and rate f respirations followed by periods of apnea • • ▪ Seen with meningitis or severe brain damage o Ataxic ▪ Significant disorganization with irregular and varying depths of respiration ▪ More extreme expression of biot respirations indicating respiratory compromise o Air trapping ▪ Increasing difficulty in getting breath out ▪ Chronic obstructive pulmonary disease, air is trapped in the lungs during forced expiration Adventitious Breath Sounds (Table 19-2) o Crackles: inhaled air opens the small deflated air passage coated in exudate ▪ Fine: high pitched, short, popping sounds heard during inspiration and not cleared with cough, sounds are discontinuous and can be simulated by rolling a strand of hair between your fingers near your ear • Occur late inspiration usually in pneumonia and CHF. Crackles in early inspiration associate with obstructive disorders such as bronchitis, asthma or emphysema ▪ Coarse: low-pitched, bubbling, moist sounds that may persist from early inspiration to early expiration; also described as softly separating Velcro • May indicate pneumonia, pulmonary edema and pulmonary fibrosis. Velcro rales of pulmonary fibrosis are louder and closer to stethoscope and usually don’t change location. Common with long-term COPD o Pleural friction rub: two inflamed pleural surfaces rubbing together ▪ Low-pitched, dry grating sound; sound is much like crackles, only more superficial and occurring during both inspiration and expiration • Occurs in pleuritis o Wheeze: air passes through constricted passage (caused by swelling, secretion, tumors ▪ Sibilant: high-pitched, musical sounds heard primarily during expiration but may also be heard n inspiration • Heard in cases of acute asthma r chronic emphysema ▪ Sonorous: low-pitched snoring or moaning sounds heard primarily during expiration but may be heard throughout the respiratory cycle. These wheezes may clear with coughing • Heard in bronchitis or single obstructions and snoring before an episode of sleep apnea. Stridor is a harsh, honking wheeze with severe broncholaryngospasm, such as croup ▪ History of Present Health Concern o Difficulty Breathing: ▪ C: Dyspnea: pulmonary disorder, COPD, asthma, pneumonia, pneumothorax, pulmonary embolism, CHF, coronary heart disease, MI, anxiety ▪ O: May occur during rest, sleep, or with mild, moderate or extreme exertion. Gradual onset indicates changes in lungs such as emphysema, • • viral or bacterial infections , asthma exacerbation, MI, pulmonary embolism ▪ L: N/A ▪ D: : May have continuous coughing “smokers cough” with sputum, shortness of breath with everyday activities, and wheezing ▪ S: with exercise or strenuous activities is normal if subsides with rest. Occurs in nonstrenuous activities of pts with lung disease or CHF ▪ P: can occur with stress or anxiety ▪ A: edema or angina (chest pain), orthopnea (difficult breathing when lying), HF, paroxysmal nocturnal dyspnea (severe dyspnea that awakens pt) changes in sleep pattern, sleep apnea, Assessment Procedure o Posterior Thorax ▪ Percussion • 16 lung fields • Resonance is percussed tone over lung tissues flat tones over scapula • Excursion equal bilaterally 3-5cm in adults • Dullness is present when fluid or solid tissue replaces air in lungs • Hyperresonance is in emphysema and pneumothorax when air trapped Assessment Procedure o Posterior Thorax ▪ Palpation • 16 lung fields • No tenderness, pain or unusual sensations, temperature should be equal bilaterally • No crepitus (trapped air escaping) • Skin free of lesions and masses • Fremitus is symmetric and easily identified in upper regions and decreases as u go downward • When takin deep breaths hands move 5-10cm bilaterally Chapter 21 • Auscultating Heart Sounds (21-1) o Where to Auscultate ▪ Anterior surface of the body overlying the heart and great vessels o Traditional Areas of Auscultation ▪ Aorta: 2nd ICS R sternal boarder ▪ Pulmonic valve: 2nd ICS L sternal boarder ▪ Erbs point: 3rd ICS at left sternal boarder ▪ Mitral valve/ apical pulse: 5th L midclavicular ICS ▪ Tricuspid valve: 4th L ICS o How to Auscultate ▪ • • • • Positioned on the right side of the patient while client is supine, with the upper truck elevated 30 degrees. Using the diaphragm of stethoscope pressed firmly on the chest on all areas of the precordium for high-pitched sounds. Use the bell for low- pitched sounds or gallops. Electrical Conduction of the Heart o Pathways ▪ P wave: atrial depolarization; conduction of the impulse through the atria ▪ PR interval: time from beginning of atrial depolarization to beginning of ventricular depolarization. From the beginning of P wave to beginning of QRS ▪ QRS complex: ventricular depolarization (also atrial repolarization); conduction of the impulse throughout the ventricles, measured from beginning of Q wave to end of S wave ▪ ST segment: period btw ventricular depolarization and the beginning of ventricular repolarization ▪ T wave: ventricular repolarization; ventricles return to resting state ▪ QT interval: total time for ventricular depolarization and repolarization, beginning of the Q wave to the end of the T wave; OT interval varies with HR ▪ U wave: may or may not be present; if present it follows T wave and represents final phase of ventricular repolarization Extra Heart Sounds (21-4) o S3: heard at the beginning of diastole in children, adolescents, and young adults o S4: herd towards the end of diastole mainly in pts age 40-50 yrs old with no evidence of heart disease o Pericardial Friction Rub: result of rubbing of two inflamed pleural surfaces ▪ low-pitched, dry, grating, sound; sound is much like crackles; only more superficial and occurring during both inspiration and expiration o Patent Ductus Arteriosus (PDA): congenital anomaly that leaves an open channel btw the aorta and pulmonary artery. Found over the 2nd L ICS, the murmur of PDA may radiate to the L clavicle. Continuous murmur b/c it extends through systole and into part of diastole. Median pitch and a harsh machinery-like sound. Loudest in late systole, fades in diastole and has silent interval late diastole. o Venous Hum: benign sound caused by turbulent blood in the jugular veins. Herd above the medial third of the clavicles, especially on the right and may radiate to the 1st and 2nd ICS. Low-pitched humming or roaring continuous murmur without silent intervals and loudest during diastole. Normal Heart Sounds o S1 & S2 ▪ Aortic: (S1 < S2) ▪ Pulmonic: (S1 < S2 ▪ Erbs pt: (S1 = S2) ▪ Tricuspid: (S1 > S2)
▪ Mitral: (S1 > S2)
o Auscultation “LUB DUB”
▪ S1: first heart sound; beginning of systole
▪ S2: end of systole
o Heart (Precordium), Anterior Chest
• Apical impulse may or may not be visible
• small gentle tap
• no pulsations or vibrations at apex, left sternal boarder or base
• radial and ulnar pulse should be identical
• rate of 60-100 beats/ min
• regular or irregular
• extra heart sounds
• murmurs: turbulent blood flow as swooshing or blowing sounds
o Neck Vessels
• Jugular vein distention (JVD
• not normally visible with client sitting upright, no distention,
bulging or protruding at 45 degrees or greater
• Indicative of R side heart failure, pulmonary hypertension,
pulmonary emboli or cardiac tamponade
• Carotid pulse: bell of stethoscope for bruits; blowing or swishing
sounds from turbulent blood flow through narrow vessels.
Indicative of arterial disease.
• Pulse Amplitude Scale
o 0= absent
o 1+ = weak
o 2+ = normal
o 3+ = strong
o 4+ = bounding
History of Present Health Concern
o Other Symptoms
▪ Need to know the following:
• Dyspnea: shortness of breath
• Orthopnea: discomfort when breathing while lying flat
• Nocturia: frequent urination at night
• Edema: fluid accumulation in extremities
• History of Present Health Concern
o PAD: Peripheral artery disease
▪ Arteries become narrowed or blocked when plaque gradually forms inside
the artery walls.
o Varicose veins: increased venous pressure and venous pooling
o Peripheral Edema: accumulation of fluid causing swelling. Usually from HF and
o Arterial disease: a bruit, blowing or swishing sound caused by turbulent blood
flow through narrowed vessel
• Characteristics of Arterial and Venous Insufficiency (22-1)
o Arterial insufficiency:
▪ Pain: intermittent claudication’s to sharp, unrelating, consistent. Ulcer
pain is very painful
▪ Pulses: diminished or absent
▪ Skin & ulcer characteristics
• Arterial: skin elevation pallor of foot, dry, shiny skin, cool to
cold, loss of hair over toes and dorsum of foot, nails thickened and
ridged. Ulcers; tips of toes, toe webs, heel or other pressure areas,
very painful depth of ulcer deep, often involving joint space,
circular. Ulcer base pale black to dry and gangrene.
o Venous insufficiency:
▪ Pain: aching , cramping. Ulcer pain is superficial, minimal pain, but may
be very painful
▪ Pulses: present but maybe difficult to palpate through edema
▪ Skin & Ulcer Characteristics
• Venous: skin; pigmentation in medial and lateral areas. Skin
thickened and tough, may be reddish-blue in color, frequently
associated with dermatitis. Ulcers medial malleolus, superficial,
minimal pain but may be painful, superficial, irregular boarder,
granulation tissue-beefy red to yellow fibrinous in chronic longterm ulcer
• Assessment Procedure
• lymphedema? Indicative of blocked circulation
• Color? Indicative of vascular disorder caused by vasoconstriction
or vasospasms of the finger and toes
• Swelling, bumps, bruises, lesions?
• Size, shape?
• Assessment Procedure
• varicose veins? Incompetent valves in veins, weak veins, or
ulcers and Color? Arterial insufficiency, venous insufficiency
Loss of hair? Indicative of arterial insufficiency
Edema? Systemic problems (HF, local problems)
Pulse? Indicate compartment syndrome, arterial insufficiency,
occlusions, bruit over femoral pulse indicate obstruction
Capillary refill? > 2sec indicate vasoconstriction, decreased cardiac
output, shock, arterial occlusion or hypothermia
Temperature? Cool indicative of arterial insufficiency
Lymph nodes indicative of infections
Types of Peripheral Edema (22-2)
o Edema Associated with Chronic Venous Insufficiency
▪ Caused by obstruction or insufficiency of deep veins. Usually unilateral;
maybe bilateral. Ulcer and pigmentation may be present
• 1+= slight pitting
• 2+= deeper then
• 3+= noticeably deep pit
• 4+= very deep pit
• Assessment Procedure
1. Sensory System
▪ CN 1: identify and distinguish smells
▪ CN 2: 20/20 vision, full visual field, round red reflex, reads print at 14 in
▪ CN3, CN 4, CN6: eyelids cover about 2mm of iris, eyes move in smooth
coordinated motions, bilateral illuminated pupils constrict simultaneously
▪ CN 5: temporal masseter muscle contract bilaterally, identify sharp and
dull on forehead, cheek and chin, eyelids blink bilaterally,
▪ CN 7: client smiles, frowns, wrinkles forehead, shows teeth, puffs out
cheeks, purse lips, raises eyebrows, closes eyes against resistance.
Movements are symmetric, identifies correct flavor
▪ CN 8: hears whisper, weber test: vibrations herd equally in both ears,
Rhinne test: AC > BC
▪ CN 9: uvula and soft palate rise bilaterally and symmetrically, gag reflex
intact. Some pts may not have gag reflex, swallows without difficulty
▪ CN 11: strong contraction of the trapezius, strong contraction of
sternocleidomastoid muscle on side opposite of turned face,
▪ CN 12: tongue movements are symmetric and smooth and bilateral
strength is apparent
2. Tests for Meningeal Irritation and Inflammation
▪ Brudzinski sign: client supine, place hands behind the pts head and flex
neck forward until chin touches the chest if possible. Hips and knees
remain relaxed and motion
3. Cranial Nerves
1. Olfactory (smell)
2. Optic nerve (Snellen chart)
3. Oculomotor (follow my finger “H”)
4. Trochlear (eye movement)
5. Trigeminal (q tip face sensation and jaw movement)
6. Abducens (eye movement in wagon wheel pattern)
7. Facial (facial movements)
8. Vestibulocochlear (hearing)
9. Glossopharyngeal (gag reflex, uvula movement)
10. Valgus (swallow)
11. Spinal accessory (shrug shoulders against resistance)
12. Hypoglossal (tongue movement)
Chapter 16 abnormal findings 16-6
Optic atrophy: white optic disc. Lack of disc vessels
Glaucoma: enlarged physiological cup. Pale base. Obscured and/or displaced retinal vessel
Papilledema: swollen optic disc. Blurred margins. Hyperemic appearance from accumulation of
excess blood. Visible and numerous vessels. Lack of visible physiologic cup
Chapter 16 abnormal finding s 16-3
Ptosis (drooping eye)
Ectropion (outward turned lower lid)
Exophthalmos (protruding eyeballs and retracted eyelids)
Chalazion (infected meibomian gland)
Subconjunctival hemorrhage (bright red area of sclera)
Blepharitis (staph infection of the eyelid)
Entropion (inward turned lower eyelid)
Diffuse episcleritis (inflammation of the sclera)
An instructor is teaching a group of students about culture. How would the
instructor define the term to students?
Experienced by all people even without human contact.
Shared system of values, beliefs, and learned patterns of behavior
Transmission to another generation through genetics
Adapted to a specific environment
4. In regards to space, which of the following cultures ‘’moves in the closet’’
When speaking to others?
A- Middle Easterners
5-The nurse is preparing to assess the tricuspid on a client’s chest. The nurse
would auscultate at which location?
Fifth intercostal space, left midclavicular line
Third intercostal space, left sternal line
Second intercostal space, left sternal border
Fourth intercostal space, left sternal border
6- A client tells the nurse that since ‘’ she woke up in the morning ‘’ Her right eye
is red and swollen. The nurse should assess the client for:
A blind spot
8- A nurse assessing a client’s radial pulse and rates it as ‘’ strong ‘’ How would
the nurse document this finding in the client’s electronic medical record?
9- A nurse is testing a client’s air and bone conduction using the Rinne Test. The
client heard the air conduction sound longer than the bone conduction. What do
the findings indicate?
Conductive Hearing Loss
Systemic hearing Loss
10- A nurse realizes that a nursing student needs further training on giving
culturally competent care when the student states which of the following ?
A- ‘’ I must use my own cultural beliefs and values when interacting with
individuals from other cultures’’
B- ‘’ I need to respect and be sensitive to the values, beliefs, and practices of
C- ‘’ I need to seek out educational opportunities to learn about different
D- ‘’ I need to collect cultural data when I take health history’’
11-A client arrives at the Emergency Room from a car accident. When the nurse
assesses the client’s right eye, the sclera has bright red areas. What abdomality
does the nurse suspect?
B- Scleral jaundice
12- What test would a nurse perform if a client reports diminished or lost hearing
in one ear?
Auditory Response Test
13- A nurse palpates a client’s leg. Which of the following would e consistent with
Skin thickened end tough
Capillary refill time of 2 seconds
Bilateral radial pulses of 2+
14- The nurse observes a client sitting at the side of the bed in the position
shown. What Health problem should the nurse suspect the client has been
15- A client arrives at the doctor’s office tired. When the nurse asks the client why
he looks tired, the client states ‘’ I have not taken any vacation time so I can save
money to buy a house .’’ Based on the client’s answer, the client has what type of
None of the above
16- The client has a history of breast cancer with reconstructive surgery. The
nurse should assess the client for what potential complication?
B- Varicose Veins
C- Peripheral arterial disease
D- Venous stasis
17- The nurse preparing to perform a spiritual assessment on a client . There are
many friends and family members at the patient’s bedside that are volunteering
information for the patient. Who should be the focus of the spiritual assessment?
B- the patient
C- The family members
D-The family and patient
19-During an ophthalmoscopic examination, the nurse notices that the client has
an enlarged physiologic cup that occupies more than half of the disc’s diameter
and displaced retinal vessels. Based on these findings, what abnormality of optic
disc does the nurse suspect ?
B- Subconjunctival Hemorrhage
C- Optic Atrophy
20- Client says that an object place in their hand is a key when the object is really
a paper clip. What test did the nurse assess?
A- Tactile Dis crimination
C- Vibratory Sensation
D- Sensitivity to Position
21- A nurse is going to percuss a client’s lungs who has emphysema. Due to the
client’s illness, what tone should the nurse anticipate?
22- A nurse wants to assess a client’s extraocular eye movements. Which cranial
nerve must the nurse assess to determine if the client’s extraocular eye
movement are normal or abnormal? ( select All That Apply)
A-Cranial Nerve III ( Oculomotor )
B- Cranial Nerve II ( Optic )
C-Cranial Nerve VI (Abducens )
D-Cranial nerve IV ( Trochlear )
23- The client states that he goes to services and prays every day and eats food
according to his Bible. He is practicing what?
24- A client arrives at the Emergency Room complaining of pain when the pinna of
the right ear is touched. The pain started after the client went for a morning swim
in their pool. What condition does the nurse suspect?
25-A nurse is assessing a client’s lower extremities at night and notices edema in
both legs. What condition is associated with bilateral edema in the lower
extremities at night?
B-Coronary Artery Disease
26-A nurse is working with a Mexican client who sees a curandero ( folk healer )
from time. Based on the client’s Mexican traditions, what preventive and healing
practices might the client follow?
Science – based Modern Nutrition
Hot and cool balance for diet
27-what does the ‘’S’’ in the SPIRIT acronym stand for?
Self- Understand of Spirituality
Spiritual Belief System
29- Which of the following is an example of a spiritual practice?
A young woman attending synagogue
A young man practicing yoga in a public park area
A couple praying at a mosque
An older man undergoing baptism as part of a church service
30- A nurse conducts an eye assessment on a newly admitted client to the
Med-Surg unit. The nurse notices that the client’s eyeballs are protruding and
have retracted eyelids. What term would the nurse use to document these
findings in the client’s chart?
31- A 58-year-old client complains that he cannot hear his adult children’s voices
when they are talking from the other side of the dining room table . What
condition does the nurse suspect?
32-A nurse in the Emergency Department tends to see her own cultures as the ‘’
Gold Standard’’ to which all other cultures should try to live by. What term can be
used to describe the nurse’s view that her culture is superior to all others?
33-A nurse assessing a client and observes several reddened areas on the skin.
Further assessment reveals that the client uses cupping to treat back pain. How is
Placing heated glass jars on the skin that are allowed to cool.
Attaching smldering herbs to acupuncture needles.
Rubbing ointment into the skin with a spoon.
Placing burning herbs directly on the skin.
35- The nurse is caring for a mother and newborn in the Labor and Delivery unit.
The nurse overhears the new mother ask family members to prepare the nursery
and purchase clothing for the baby. What would the culturally sensitive nurse
A- The new mother’s culture believes in not buying baby clothes before the
B- The new mother needs to learn how to care for a baby.
C- The new mother cannot afford clothing for the baby.
D- The new mother is young, and the baby is not wanted.
36- A nurse needs to assess the strength and mobility of a client’s tongue. Which
cranial nerve does the nurse need to assess to make this determination?
CN X ( vagus)
CN IX ( Glossopharyngeal)
CN XII (Hypoglossal)
CN V (Trigeminal)
37- A client arrives at the health care clinic with a 2-day history of pain in the neck
and resistance to flexion. The nurse suspects meningeal inflammation, what test
should the nurse perform?
Rebound Tenderness Sign
38-A nurse is assessing a patient’s peripheral edema. When the nurse palpates
the patient’s left dorsalis pedis pulse site a ‘’ Noticeably deep pit’’ or indentation
is left on the foot. How would the nurse document this pitting edema as?
39- When assessing a client’s tympanic membrane, the nurse is aware that the
tympanic membrane should be what color in a healthy ear?
40- When describing the cardiac cycle to a group of students, the instructor
correlates heart sounds with events of the cycle. Which heart sound would the
instructor explain as being associated with the beginning of diastole?
41-Two days ago, a hospitalized client was diagnosed with a stroke. The nurse
needs to check a client’s ability to swallow before giving them a cup of tea. Which
cranial nerve does the nurse need to assess to determine if the client client can
swallow without difficulty?
Cranial Nerve XI (Spinal Accessory )
Cranial Nerve XII (Hypoglossal )
Cranial Nerve IX (Glossopharyngeal ) or X ( Vagus )
Cranial Nerve VII (Facial )
42- A nurse is testing a client’s extraocular muscle function by performing the
cover test. As the client states straight ahead, the uncovered eye turns inward.
What this condition called?
43-A nurse is preparing to conduct an initial interview on a patient from a
different culture. Which of the following is important for the nurse to consider
before beginning the interview?
Economic status of the patient
Verbal and nonverbal communication
Specific talents of the patient
44- A client in the Emergency Room (ER) tells the nurse that she is having
difficulty breathing at rest. What term would the nurse use in documenting this
45- What eye function is the nurse preparing to assess when the patient is asked
to stand 20 feet from a Snellen chart that is mounted on the examination room
Eye Muscle Movement
46- Which major World region views illness as a ‘’Trial sent by God and the
outcome depends on the person’s attitude of pious endurance?
47- A nurse is assessing a client’s sensory system. The nurse uses the eraser of a
pencil to write a number on the palm of the client’s hand. What is the nurse
Two Point Discrimination
48- A nurse is assessing an older adult client who fell. The client states that when
he sits up, ‘’ He feels like he is spinning.’’ Basses on the client’s description,what
condition does the nurse suspects?
49- The nurse is assessing a 60-year-old woman’s risks foe lung disease. The
woman states, ‘’ it shouldn’t be a problem for me. My husband smokes quite
heavily but I’ve been a lifelong nonsmoker.’’ The nurse should recognize the need
to teach the client about what topic?
Strategies for making her husband quit smoking
Health Risks of secondhand smoke
Genetic causes of lung cancer
Age- related changes to respiration function
50- Auscultation of a client’s lungs reveals the presence of a wheeze. The
nurse should recognize that this adventitious sound from what
Air being diverted from the trachea to the bronchi
Air passing through constricted passageways
Air increasing in turbulence in a wide passage
Air leaking from the alveoli into the pleural space
51-Which major world religion religion states that’’ suffering is a part of human
52-The nurse asks a 55-year old client to hold a pocket screener 14 inches from
his eye. What is the nurse assessing?
53- A patient from Spain is used to having lunch at 2 pm. However, the hospital
serves lunch between 11 am and 12 pm (noon). What should the nurse do?
A- Tell the patient to not eat lunch since it is delivered earlier than he likes.
B- Arrange for the patient’s lunch to be delivered at 2 pm.
C- Ash the patient’s family to bring lunch for the patient every day until he is
discharged from the hospital.
D- Tell the patient he has to eat lunch when the food arrives at 11 am.
54- A client in the Emergency room is diagnosed with a stroke. Based on the
client’s diagnosis, which abnormality of the external eye is an expected finding?
55-Which of the following may cause varicose Veins?
57- A 57-year-old maintenance worker comes to the doctor’s office for
evaluation of pain in his legs. He his a two-pack per day smoker since the age of
16, but he is otherwise healthy. The nurse is concerned that the client may have
peripheral vascular disease. Which of the following is a common or concerning
symptom of the peripheral vascular system?
Shortness of breath
Chest Pressure with Exertion
58- A nurse asks a client lying in a supine position to bend the knee and move it
out of the way. The nurse then ‘’presses three fingers deeply and slowly below
and medial to the inguinal ligament. ‘’ The nurse is palpating the pulse of which
59- During a physical examination, the nurse detects warm skin and brown
pigmentation around an adult’s client’s ankles. The nurse suspect that the client
may be experiencing.
Arterial occlusive Disease
60- The nurse is preparing to examine the ears of an adult client with an
otoscope. The nurse should plan to do which of the following to view the
Ask the client to move the head forward
Ask the client to lay down in a supine position
Firmly pull the client’s auricle down and back
Firmly pull the client’s auricle out, up, and back
61-A nurse States’’ all Hispanics are afraid of going to the doctor and getting bad
news’’. What term can be used to described the nurse’s statement about
62- A client arrives at the Emergency Department with lower abdominal pain. The
patient states that she is here in the United States for a business meeting but is
from France . What cultural beliefs and values does the nurse need to include in
the health assessment?
Does the client see the doctor in the regular basis in France?
Does the client practice alternative medicine?
The client’s beliefs about health, illness, and healing.
Call the client family to find out about the client’s healthcare preferences.
63- During the admission assessment, the nurse learns that the client has a
history of Raynaud’s Disorder. What assessment finding would the nurse expect
Cool fingers and hands
Capillary refill less than 2 seconds
Cool leg on one side
Cool legs bilaterally
64-Which action by a nurse demonstrates proper technique for assessment of
A- Beginning at the scapular line, percuss the intercostal spaces along both sides
of the posterior chest
B- Place the stethoscope on the posterior chest wall, ask the client to take deep
breath, and observe chest rise and fall
C- Place both hands on the posterior chest at T9 or T10, press thumbs together,
and then ask client to take deep breath
D- Use the ball of both hands to feel for vibrations in a symmetrical pattern
across the posterior chest
65-A nurse is assessing a client and notices excessive tearing in both eyes. Based
on the client’s symptoms, what does the nurse suspect?
D- Viral infection
66-What does the “C” in the FICA acronym stand for?
67-The nurse plans to test which cranial nerve when testing an elderly patient’s
hearing ability in each ear?
CN VIII (Vestibulocochlear)
CN V (Trigeminal)
CN VI (Abducens)
CN IV (Trochlear)
68- A client complains of difficulty sleeping, stating he has to sit up with the help
of several pillows and cannot breathe when lying flat. This client has a condition
known as what?
69- While performing an admission’s assessment on a client, the nurse
auscultates a ‘’ medium-pitched, harsh, machinery- like sound’’ The nurse should
use what term to document this extra heart sound?
Pericardial Friction Rub
Patent Ductus arteriosus
70- A client reports pain in the legs that begins with walking but is relieved by
rest. Which condition should the nurse assess the client for?
A- Varicose Veins
B- Diabetes mellitus
C- Peripheral arterial disease
D- Calcium deficiency
71-A client arrives at the Emergency Room after overdosing on narcotics. A nurse
conducts a respiratory assessment and notices that the client’s respiratory
pattern is ‘’ decreased rate decreased length, and irregular pattern’’ Based on the
respiratory pattern, the nurse documents the findings using what term?
72-When auscultating a client’s lungs, the nurse hears a ‘’ low pitched, dry,
grating sound ‘’ That occurs during inspiration and expiration. How should the
nurse document this finding?
Pleural friction Rub
73-A nurse is testing a client’s vibratory sensation. The nurse strikes the tuning
fork and places it on the client’s medial malleolus. The client does not sense the
vibrations. What condition does the nurse suspect?
74- What is the definition of assimilation?
A-The universal tendency of humans to think that their ways of thinking,
acting, or believing is the only right and proper way
B- An oversimplified conception, opinion, or belief about some aspect of an
individual or group
C- The gradual adoption and incorporation of characteristics of the prevailing
D- The intrusive application of the majority group’s cultural view upon
75- How should a nurse assess a client for pulse rate deficit?
Auscultate for split S1 at the base and apex
Check for pulse inequality between right and left carotid arteries
Assess for a difference between the apical and radial pulse
Observe for a decrease in jugular venous pressure
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