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Unit 4 Exam PA

Physical Assessment

QuestionAnswer
What are the two parts of an Admission Assessment? Nursing History Physical Assessment
The Nursing History provides what type of data? Subjective data
The Physical Assessment provides what type of data? Objective Data
What are the 5 dimensions of the client that a comprehensive health assessment encompasses? Physiological, psychological, sociocultural, spiritual, and developmental.
Why is it important to perform a thorough Admission Assessment? All further assessments will be compared to it to determine improvement. (Baseline info)
What are the 4 purposes of a Physical Assessment? 1. ID Pt's healthcare needs 2. Determine priority of care and expected outcomes. 3. Establish a Nursing Care Plan. 4. Communicate the Pt's health status.
How soon after the Pt has been admitted should a Physical Assessment be performed? Within 24 hours
What involves the use of all senses but taste to obtain info about the structure and function of an area of the body that is beig observed or manipulated? Physical Exam/ Physical Assessment
Which part of the stethoscope detects low pitched sounds? The bell
What types of sounds can be heard with the bell of a stethoscope? heart murmurs, bruits, abnormal heart sounds
What types of sounds can be heard with the diaphragm of the stethoscope? breath sounds, normal heart sounds and bowel sounds
What part of the stethoscope detects high pitched sounds? The diaphragm
What is an ultrasonic device that detects blood flow through a vessel? A doppler.
When should a doppler be used? When a pulse cannot be palpated.
What are the 4 Assessment techniques? Inspection, palpation, percussion, auscultation
What is the systematic and deliberate visual observation used to determine health status? Inspection
When during the physical assessment should the nurse use inspection? Throughout the entire assessment.
What 6 things can palpation determine? position, size, fluid, mass, vibration, temperature
What parts of the nurse's body should be used for palpation? palmar surfaces of the fingers and pads, ulnar surfaces of the hands and fingers, and the dorsal surfaces of the hands(temperature)
How much force should the nurse exert when palpating a patient? Use light touch first, then palpate deeper unless Pt expresses pain
Which assessment technique is used to determine if organs or tissues are swollen, edemic or necrotic? Percussion
What type of sounds are heard when a nurse percusses over air? loud sounds
What causes soft sounds to be heard while using percusson? Percussing over solids
Where on the body is percussion most usually used? Over lungs and abdomen
When during a physical assessment should auscultation always be performed? Last, except with abdominal sounds, where it is done first.
What happens if the nurse auscultates the bowel sounds after palpating or percussing? The bowel is stimulated and the sounds heard will be in reaction to that, not normal bowel sounds.
What terms should be used to describe sounds heard when auscultating? duration, pitch, intensity, quality, location
What are some examples of words used to describe duration? long, short, continuous, interrupted
What are some examples of words used to describe quality? whistling, gurgling, snapping, rubbing
When should vital signs be checked: before, during, or after a physical assessment? Before
At what degree should the HOB be raised to to check for JVD? 45 degrees
What is JVD? Jugular Vein Distention
What causes JVD? Fluid overload causes jugular vein to pulsate and bulge.
What is JVD a sign of? Pulmonary hypertension and/or congenitive heart disease/failure
What is considered "sluggish" in regards to capillary refill? More than 3 seconds
What are terms used to describe skin color? pink, pale, cyanotic, grey, mottled
What are terms used to describe skin temperature? Cold, cool, hot, warm, feverish
When pulses are palpated, which ones are counted and which ones are graded? Apical and radial counted, others graded.
What doess a pulse grade of 0 mean? Absent
What does a pulse grade of 1+ mean? Barely palpable, difficult to feel
What does a pulse grade of 2+ mean? "Normal", detected readily, obliterated by strong pressure
What does a pulse grade of 3+ mean? Bounding, easy to find, difficult to obliterate
What is tissue that has extra interstital fluid? Edema
When edema leaves an indention when pressed and the finger is pulled away it is said to be what kind of edema? Pitting edema
What is a 1+ on the Edema scale? Barely detectable, less than or equal to 2 mm
What is a 2+ on the Edema scale? Indentation of more than 2 mm but less than or equal to 5 mm
What is a 3+ on the Edema scale? Indentation of more than 5 mm to 10 mm
What is a 4+ on the Edema scale? Inentation of more than 10 mm
Which heart sound is heard when the mitral and tricuspid valves close? S1
Which heart sound is heard when the aortic and the pulmonic valves close? S2
Which heart sounds can be heard at all auscultation sites? S1 and S2
What are the sounds of abnormal blood flow caused by valves not closing properly? Murmurs
What is caused when heart valves do not close properly due to stenosis? Valvular regurgitation
Which heart sound is commonly referred to as "lub"? S1
Which heart sound is commonly referred to as "dub"? S2
Which abnormal heart sound occurs because the left ventricle doesn't work properly? S4
Which abnormal heart sound is a common sign of congestive heart failure? S3
What is air trapped in subcutaneous tissue called? Crepitus
What is a high pitched sound caused by the narrowing of bronchi that is usually heard on expiration? Wheezing
What is a rumbling or gurgling sound heard during expiration called? Rhonchi
What high pitched breath sounds sound like hair rubbing together? Crackles/rails
Which lung sounds are caused by secretions sitting in the upper lungs? Rhonchi
Which lung sounds are scratchy and high pitched? Rub
Which lung sounds are caused by fluid in the alveoli of the lower lung? Crackles
What are the four quadrants of the abdomen? RLQ, RUQ, LUQ, LLQ
How should a client be positioned for an abdominal assessment? Flat on back with knees slightly bent and arms at sides.
How many sites should be auscultated during the abdominal assessment? 2 areas per quad, 8 total
Why should you measure the girth of a patient around the umbilicus? To check for distention
How would you describe bowel sounds that are heard every 5 - 10 seconds? Active/Normal
How would you describe bowel sounds that are heard less than 5 seconds apart? Hyperactive
How would you describe sounds heard over the bowel that occur more than 15 seconds apart? Hypoactive
How would you describe bowel sounds where no sounds are heard for a full 5 minutes over all quads? Absent
What is the "boom" like sound heard when purcussing over a cavity with air in it? Tympany
Where is tympany considered normal to be heard? Over the stomach
Where should tympany never be heard? Over the intestines
what kind of sound is normally heard over fluid or fecal masses? A dullness
Why should be done to confirm whether tymphany in intestines is gas or free air? X-RAY
What causes white patches on oral mucosa? Thrush (yeast)
What does it mean to be oriented X 4? Oriented to person, place, time and situation
Upon entering patient room, the nurse should attempt to get the patient's attention by what means first? Verbally
Upon entering patient room, the nurse should attempt to get the patient's attention by what means second? Light touch
Upon entering patient room, the nurse should attempt to get the patient's attention by what means as a last resort? Painful, noxious stimuli
How long does it take for IV pain medication to take effect? 5-15 minutes
How long does it take for oral pain medication to take effect? Up to an hour
What is the name of the medication that can reverse an overdose, be it accidental or intentional? NARCAN
What does PERRLA stand for? Pupils Equally Round and Reactive to Light and Accomodation
When checking pupils for their reactivity to light, what is the term for when you shine the light into one pupil and the other reacts spontaneously? Consensual pupillary reaction
When eyes are focused on something in the the distance, will the pupils be dilated or constricted? Dilated
What is the term for when pupils constrict to better see something close up? Accomodation
How do you check Homan's sign? Support calf and force dorsifelexion
What happens if a sharp pain is felt in the calf when checking for the Homan's sign? Most likely a clot or a DVT
Which problem below has the greatest potential for precipitating hyperkalemia? Diaphoresis, vomiting, diarrhea, burns Burns. during the first 24 hours after a burn, K is elevated in the blood stream because of the destruction of tissue and oliguria.
A Pt's BP is 140/90 mm HG. The Pt's pulse pressure is: 140-90=50
Which is most likely found while assessing an older adult? An increase in: Nail growth, skin elasticity, urine residual, or nerve conduction? Urine residual
Which assessment technique is the most informative concerning a pt's respiratory status? Auscultation
Why should a nurse wait 2 minutes after taking a PT's BP to take it again? Allows for venous return and prevents falsely elevated results.
How long after a PT drinks icewater should a nurse wait to obtain the PT's oral temperature? 15 minutes
The normal range for respirations is how many breaths per minute? 14-20
Created by: cestes1001
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