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Advanced Health Assessment Red Flags Question and answers rated A+ 2025, Exams of Nursing

Newcastle UniversityNursing

Advanced Health Assessment Red Flags Question and answers rated A+ 2025

Typology: Exams

2024/2025

Available from 07/04/2025

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Advanced Health Assessment Red Flags
Eye - correct answer • Pain (not discomfort or irritation)
• Decreased vision
• Profuse discharge
• Corneal defect grossly visible
Ocul
External swelling and redness - correct answer Malignant otitis externa or mastoiditis
Light yellow to dark brown matter that occludes the eardrum - correct answer cerumen impaction
Bloody discharge - correct answer External ear canal wound, skull fracture, traumatic perforation of the
tympanic membrane
Purulent discharge - correct answer Infection or a foreign body
Whitish plaques on the eardrum - correct answer Scars from earlier infection
Dark area on the eardrum with drainage - correct answer Old or current perforation
Diffuse light reflex - correct answer Bulging eardrum
Bubbles on the eardrum - correct answer Serous fluid in the middle ear
Otitis, crying, or fever - correct answer Erythema of the tympanic membrane
Nose and Sinuses - correct answer Epistaxis is persistent, recurrent, or profuse.
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Advanced Health Assessment Red Flags

Eye - correct answer • Pain (not discomfort or irritation)

  • Decreased vision
  • Profuse discharge
  • Corneal defect grossly visible Ocul External swelling and redness - correct answer Malignant otitis externa or mastoiditis Light yellow to dark brown matter that occludes the eardrum - correct answer cerumen impaction Bloody discharge - correct answer External ear canal wound, skull fracture, traumatic perforation of the tympanic membrane Purulent discharge - correct answer Infection or a foreign body Whitish plaques on the eardrum - correct answer Scars from earlier infection Dark area on the eardrum with drainage - correct answer Old or current perforation Diffuse light reflex - correct answer Bulging eardrum Bubbles on the eardrum - correct answer Serous fluid in the middle ear Otitis, crying, or fever - correct answer Erythema of the tympanic membrane Nose and Sinuses - correct answer Epistaxis is persistent, recurrent, or profuse.
  • Severe maxillary pain.
  • Thin, honey-colored sinus drainage following head trauma may indicate skull fracture. Mouth and Throat - correct answer Persistent, painless mouth lesions or lesions consistent with malignancy require referral.
  • Sore throat associated with drooling or stridor indicates potential epiglottitis or peritonsillar abscess.
  • Sore throat lasting more than 1 week suggests untreated streptococcal pharyngitis and/or tonsillitis. Abdominal Pain (1) - correct answer • Pain that awakens patient
  • Pain that persists more than 6 hours and progresses in intensity • Pain that changes location
  • Associated syncope
  • Pain followed by vomiting or intractable vomiting
  • Hematemesis
  • Black, tarry stools hypovolemic shock Abdominal Pain (2) - correct answer • Progressive abdominal distention
  • Pain worsened by movement, respirations
  • Radiation of the pain to shoulder (cholecystitis) or back (pancreatitis/aneurysm)
  • Decreased urine output • Fever, leukocytosis, granulocytosis
  • Pain associated with signs of Genitourinary Red Flags (1) - correct answer Gross hematuria must be referred urgently to a urologist, with accompanying studies arranged and, if possible, completed before the appointment. •Abrupt onset or worsening testicular pain, regardless of patient age
  • Anuria and oliguria require aggressive evaluation and/or admission for management.
  • Acute urinary retention must be referred to the nearest emergency department immediately.

Pain in the Neck (1) - correct answer • History of injury/trauma preceding onset of pain

  • Associated neck stiffness (nuchal rigidity) with fever
  • Neck pain in a child
  • Pain that is unrelenting and/or worsening in patients who have tried and failed conservative treatment
  • Acute, severe pain, with or without radicular symptoms, upon awakening in the morning Pain in the Neck (2) - correct answer • Pain relieved by elevating the arm above the head on the side of the pain
  • Severe pain, with or without radicular symptoms, on flexion or extension of the neck
  • Chronic neck pain with weakness of upper or lower extremities, stumbling, muscle atrophy, bowel or bladder incontinence
  • Pain with a history of malignancies Back Pain Red Flags - correct answer Pain associated with neurological deficits (weakness, altered sensation, bowel/ bladder changes)
  • Pain in a child
  • Pain associated with fever and/or stiff neck
  • Pain associated with unexplained weight loss with or without a previous history of malignancy
  • Pain worse at rest
  • Pain associated with radiation to the abdomen or stomach area • Pain related to history of urinary tract infections, drug use, or other infections(including AIDS)
  • Pain increases with coughing/sneezing or straining Headache Red Flags - correct answer Acute onset, severe headaches described as "the worst headache of my life" in a patient who has no history of headache
  • Unrelenting headaches, unrelieved with conservative treatments or with pain that steadily worsens
  • New-onset headaches in patients over 50 years of age without previous history of headache
  • Lancinating, "ice-pick" head pain
  • Severe headaches associated with a stiff neck and/or fever
  • Headache accompanied by a change in mentation or level of consciousness
  • Persistent headaches following trauma to the head or neck
  • Headaches that are significantly different in pattern or severity in a patient with a long-standing chronic headache history Mental Health Red Flags - correct answer • Acute changes associated with fever, stiff neck, or headache
  • Acute changes in the elderly (patient should be worked up for a possible infectious process, particularly urinary tract infections)
  • Acute changes associated with any type of head trauma
  • Progressive changes associated with gait disorder or incontinence
  • Gradual but significant changes Dizziness/ Vertigo Red Flags - correct answer • Near fainting or fainting
  • Slurred speech, numbness of the face or limbs, or loss of limb movement
  • Visual changes, particularly diplopia
  • Acute onset, associated with nausea/vomiting Medications that cause Anxiety - correct answer • Caffeine
  • Thyroid medications
  • Theophylline
  • Albuterol Infant Head size red flags - correct answer • No growth in head circumference between well visits.
  • Enlarged head size or excessive growth between well visits. Eye Exam Red Flags (Kids) - correct answer • Presence of white instead of red reflex may indicate retinoblastoma; an absent red reflex or opacity of the lens may indicate cataracts
  • Dilated and fixed pupils, which indicate severe brain damage
  • Strabismus, which requires referral to ophthalmology for further evaluation
  • Blood in stool or emesis
  • Chronic diarrhea or constipation
  • Severe abdominal pain or guarding
  • Abdominal mass Kids GU Red Flags - correct answer • Ambiguous genitalia
  • Premature puberty
  • Hypospadias
  • Scrotal pain Kids MSK Red flags - correct answer Refusal to bear weight or walk
  • Refusal to use or bend an arm
  • Heat, redness, or swelling of one or more joints
  • Hip clunks
  • Toe walking—can be a normal phase and also can be associated with cerebral palsy, tight heel cords, autism, or muscular dystrophy Kids Neuro Red Flags - correct answer Absence, or persistence past the expected age, of newborn reflexes • Spasticity or poor muscle tone • Unresponsiveness or depressed level of consciousness • Any loss or regression of developmental milestones • Abnormal cranial nerve responses Autism Red Flags - correct answer No big smiles or expressions of happiness by 6 months • No back-and- forth sounds, gestures, or facial expressions by 9 months • No babbling by 12 months • No pointing, waving, or reaching by 12 months • No words by 16 months • No 2-word phrases by 24 months (without imitating) • Any language regression or unusual use of language Skin Red Flags - correct answer • Any mole or lesion that is changing, has irregular borders, or is growing should be examined by a dermatologist.