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Physical Asses/Tests
Physical Assessment and Special Exams/ Tests
Question | Answer |
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List four purposes of a physical assessment. | Evaluate client's current physical condition, detect early signs of developing health problems, establish a baseline for future comparisons, evaluate client responses to medical and nursing interventions. |
Name four assessment techniques. | Inspection, percussion, palpation, and auscultation. |
List at least five items needed when performing a basic physical assessment. | The nurse needs gloves, exam gown, cloth or paper drape, stethoscope, penlight, and tongue blade, as well as other instruments for taking vital signs/height and weight. |
Discuss at least three criteria for an appropriate assessment environment. | The assessment environment should be near a restroom, private, warm, and adequately lit. There should be an adjustable bed/table. |
Identify at least five assessments that can be obtained during the initial survey of clients. | Physical appearance, level of consciousness, posture, gait, movement, body size, mood/emotional tone. |
State two reasons for draping clients. | Drapes during a physical exam protect the client's modesty and provide warmth. |
Differentiate a head-to-toe and a body systems approach to physical assessment. | Head-to-toe involves gathering data from the top of the body to the feet. Body systems organizes data collection according to the functional systems of the body. |
List six ways in which the body may be divided for organizing data collection. | The head and neck, the chest, the extremities, the abdomen, the genitalia, and the anus and rectum. |
Identify two self-examinations that nurses should teach their adult clients. | Teach adult male clients how to perform testicular self exams; and adult females how to perform self breast exams. |
Differentiate between an examination and a test. | An exam is a procedure that involves the physical inspection of body structures and evidence of their functions. A test involves the examination of body fluids or specimens. |
List 10 general nursing responsibilities related to assisting with special examinations and tests. | Ensure the client understands procedure, get consent form signed, follow test prep requirements, obtain equipment/supplies, arrange the exam area, position/draping clients, assisting examiner, provide support for client, care for specimen, rec./report |
Name five positions commonly used during tests or exams. | Supine, prone, dorsal recumbent, sims, lithotomy, knee-chest, and modified standing position. |
Explain what is involved in a pelvic exam and a Pap test. | A pelvic exam involves the inspection and palpation of the vagina and adjacent organs. This exam often includes the collection of secretions for a Pap test to ID abnormal cells, level of hormone activity and ID infectious organisms. |
List six commonly performed categories of tests or exams. | Specimens, x-rays, endoscopes, radioactive substances, sound waves, and electric activity. |
Identify four word endings and their meanings that provide clues as to how tests or exams are performed. | graphy, as in angiography, means to record an image, scopy, as in bronchoscopy, means to look through a lensed instrument; centesis, as in amniocentesis, means to puncture; and metry, as in pelvimetry, means to measure with an instrument. |
Explain the following procedures: sigmoidoscopy, paracentesis, lumbar puncture, throat culture, and measurement of capillary blood glucose. | Sigmoidoscopy - inspecting the rectum and sigmoid section of the lower intestine with an endoscope. paracentesis- puncturing the skin and withdrawing fluid from the abdominal cavity, lumbar punture- inserting needle b/w lumbar vertebrae in spine. |
Discuss at least three factors to consider when performing exams and tests on older adults. | Preventing fatigue, and dehydration, maintaining or adjusting current drug therapy and avoiding misinterpretation of lab test results that are based on norms for younger adults. |