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Phys Assess TAS
Physical Assessment NP1 Test 4
| Question | Answer |
|---|---|
| Two aspects of assessment are: | nursing health history and physical examination |
| What are the three types of physical assessment? | 1. complete assessment 2. body system 3. body area |
| Purposes of physical assessment | 1. obtain client baseline 2. supplement, confirm or refute nursing history 3. help establish nursing diagnoses and plans of care 4. evaluate outcomes of care 5. make clinical judgments about client's health status 6. identify areas of health promotio |
| What is important to determine BEFORE starting a physical exam? | 1. Any positions that are contraindicated for a particular client 2. Beliefs that would hinder physical assessment |
| What are the four primary methods of examination? | 1. Inspection 2. Palpation 3. Percussion 4. Auscultation |
| Why should light palpation ALWAYS precede deep palpation? | Heavy pressure on fingertips can dull the sense of touch |
| Why is deep palpation not usually done during a routine examination? | It requires significant skill and can cause damage if not performed correctly |
| What are the two types of auscultation? | 1. Direct 2. Indirect |
| Define the two types of auscultation | Direct is listening with the unaided ear, while indirect is with the aid of a device, such as a stethoscope |
| How are auscultated sounds defined? | pitch, intensity, duration, frequency |
| Define auscultation pitch | the frequency of the vibrations |
| Define auscultation intensity | the loudness or softness of the sound |
| Define auscultation duration | length (long or short) of the sound |
| Define auscultation quality | subjective description (whistling, gurgling, ect.) |
| What is a general survey? | The first part of a health assessment, including: general appearance and mental status vital signs height weight |
| What is included in the integument? | skin, hair and nails |
| Pallor | The result of inadequate circulating blood and reduction in tissue oxygenation |
| Where is pallor most easily identified? | In areas of least pigmentation, such as conjunctiva, oral mucous membranes, nail beds, palms of hands, soles of feet |
| Cyanosis | bluish tinge |
| Jaundice | yellowish tinge |
| Erythema | redness |
| Vitiligo | patches of hypo pigmented skin |
| Edema | excess interstitial fluid |
| What is the angle of a normal nail bed? | less than 160 degrees |
| What is the process of physical assessment? | 1. Interview client and physical exam 2. Gather data within 24 hrs of admission 3. Record data on data base form 4. Establish plan of care based on info obtained |
| What does the bell of the stethoscope detect? | low-pitched sounds, such as heart murmurs and bruits |
| What is a bruit? | narrowing of a blood vessel |
| What does the diaphragm of the stethoscope detect? | high pitched sounds, such as breath sounds, normal heart sounds, bowel sounds |
| What side of the stethoscope is used most frequently? | The diaphragm |
| When is a doppler used? | When a pulse cannot be palpated |
| T or F, Inspection means you are watching for cues throughout the physical exam. | True |
| What does palpation determine? | position, size, fluid, mass, vibration, temperature |
| T or F, The kidneys are easily palpable during an abdominal exam. | False. The kidneys are not usually felt unless there is an extreme reason. |
| What is the most important aspect of auscultating? | A QUIET environment |
| T or F, When performing a physical exam, always palpate first. | False. When examining the abdomen, palpation must be done last to prevent false bowel sounds. |
| T or F, The following auscultation description is complete: Continuous high pitched gurgling heard in abdomen. | False. DETAILED LOCATION must be included, ex. Right Upper Quad |
| When during a physical assessment should vital signs be measured? | FIRST! |
| T or F, A nurse can assess in any order, and can change assessment method from patient to patient. | False. Approach must be systematic, and must be used every time. |
| T or F. Evaluating bedside equipment is not a part of physical assessment. | False. Always compare equipment to info given in report, and make sure functioning/set properly |
| What angle should the bed be positioned at when detecting jugular vein distention? | 45 degrees |
| What are the three main parts of circulation inspection? | 1. Color 2. Capillary refill 3. Jugular vein distention |
| What are the four main parts of circulation palpation? | 1. Skin temperature 2. Pulses (Apical counted, others graded) 3. Quality of peripheral pulses 4. Edema graded |
| What is the pulse grading scale? | 0 absent 1+ difficult to feel 2+ normal 3+ bounding |
| T or F, Normal for grading pulses differs from institution to institution. | False, Normal is ALWAYS 2+ |
| What is the edema grading scale? | 1+ = 2mm (barely detectable) 2+ = 4mm (indentation) 3+ = 6mm 4+ = 8mm |
| What is pitting edema? | When finger indentation remains, usually 3+ or 4+ |
| What are the auscultation sites for heart sounds? (All Physicians Take Money) | Aortic, Pulmonic, Tricuspid, Mitral |
| What is a S1 heart sound? | When the mitral and tricuspid valves close. (Lubb) |
| What is a S2 heart sound? | When the aortic and pulmonic valves close. (Dubb) |
| What is a S3 heart sound? | An abnormal extra heart sound (Ken' tuck y) |
| What is a S4 heart sound? | Abnormal heart sound (Tenn es see') |
| What can a S3 heart sound indicate? | Above the age of 13-14, could indicate congenital heart defect |
| T or F, An S3 heart sound in a child is reason for concern. | False. Can be heard in healthy children, but usually disappears by age 13-14. |
| T or F, An S4 heart sound is ALWAYS abnormal. | True. Indicates left side of heart not functioning properly. |
| What is another term for S3 and S4 heart sounds? | Gallop |
| What heart sound is a possible indication of pericarditis? | Rub |
| What is the heart murmur grading scale? | 0=absent 1=barely hear 2=faint 3=moderately loud 4=loud 5=barely use stethoscope 6=don't need a stethoscope |
| What is a heart murmur? | Prolonged heart sound caused by some disruption in blood flow through heart |
| What can cause a heart murmur? | Valvular regurgitation or stenosis |
| What does a pansystolic heart murmur sound like? | Two swishes |
| What are the four main parts of aeration inspection? | 1. Shape of chest 2. Skin color 3. Breathing effort 4. Trachea positioning |
| If the trachea appears to be off-center, what could be indicated? | Collapsed lung |
| What cues indicate troubled breathing? | Labored breathing or use of accessory muscles |
| What are the three main parts of aeration palpation? | 1. Feel for tenderness, bulges, unusual movement 2. Thoracic expansion 3. Check for crepitus |
| What are the anterior lung fields? | right upper lobe, right middle lobe, right lower lobe, left upper lobe, left lower lobe |
| What are the posterior lung fields? | right upper lobe, right lower lobe, left upper lobe left lower lobe |
| Rhonci | Gurgling sound best heard on expiration, usually in upper airways |
| What causes Rhonci? | secretions |
| Crackles are also called... | Rales |
| Crackles/Rales | Sounds like hair rubbing near ear, indicates fluid in alveoli |
| How are crackles/rales graded? | fine or course |
| Wheezing | high-pitched sound from narrowing of bronchi or bronchus, best heard on expiration |
| How can a nurse determine between a pulmonary rub and a cardiac rub? | Ask the patient to hold their breath, if continues, rub is CARDIAC |
| What is the minimal acceptable amount of urine output? | 30 mL per hour |
| What 4 aspects of patient's urine should be recorded? | 1. output over 24 hrs 2. color 3. clarity 4. odor |
| What is the best patient position for abdominal assessment? | Flat with knees bent and arms resting at sides |
| How would you describe a patients abdomen if it is swollen like a balloon? | Distended |
| What range is normal for bowel sounds? | Every 5-15 seconds |
| What is another term for normal bowel sounds? | Active |
| What is the minimal number if sites that should be auscultated in each abdominal quadrant? | 2 |
| What are the three terms used to describe bowel sounds? | 1. active 2. hyperactive 3. hypoactive |
| T or F, If a pulsation is noticed in the abdomen, it should be palpated and graded. | False. Never palpate a pulsation in the abdomen as it could be an aortic aneurysm. |
| What should be recorded if a patient has a distended abdomen? | Girth size (measured at umbilicus) |
| A nurse thinks her patient has absent bowel sounds. What should she do next? | Listen for five full minutes before recording |
| Abdominal fat is... | soft |
| Abdominal air/fluid is... | taut |
| In what order should the abdomen be palpated? | Start in the right lower quad, and continue counter clockwise until ending in the right upper quad. |
| When should patient weight be obtained? | On admission |
| What 2 lab values are most important concerning urinary elimination? | 1. Blood Urea Nitrogen 2. Creatine |
| What are the seven most important areas of assessing nutrition/metabolism? | 1. Height/weight 2. Input/Output 3. Diet 4. Oral cavity 5. Lab values 6. IV fluids 7. Skin turgor |
| What lab values are important to nutrition/metabolism? | electrolytes, RBC's, Hgb, Hct, liver profile, heart profile |
| What is EBL? | Estimated blood loss |
| Where can estimated blood loss amounts be found? | Anesthesia Record |
| What is the equation for determining caloric intake for tube feedings? | mL fluid x calories per mL |
| What are the best sites for assessing skin turgor? | Upper extremities and sternum |
| What does "tented" skin turgor indicate? | dehydration |
| Ecchymosis | bruise |
| What are the main areas assessed for patient sensation/perception? | Gait, orientation, attitude, skin integrity, IV sites, skin sensation, vision/hearing, mental status |
| What details should be recorded concerning rashes? | Size, location, raised, flat, ect. |
| What should be watched for at IV sites? | redness, tenderness, streaking, phlebitis, swelling |
| What are the aspects of assessing pain? | 1. scale of 0-10 (What does it mean?) 2. location 3. description (dull, sharp) 4. What makes it worse/better? |
| How is pain medication best monitored? | 1. Time last administered 2. Amount last administered 3. How effective was last does? 4. Level of consciousness, V/S |
| A nurse is walking into the room of a patient that may have a head injury. How does she approach the patient and check for orientation? | 1. Verbal stimuli 2. Light touch 3. Painful stimuli |
| What does PERRLA stand for? | Pupils equally round and reactive to light & accommodation |
| What 4 aspects of mobility should be assessed? | 1. ROM, assistive devices 2. Hand and leg strength bilaterally 3. All 4 extremities move equally 4. ADLs |
| What are the seven aspects of assessing anxiety? | 1. Level 2. Behavior 3. Cognitive function 4. Learning needs 5. Support 6. Family/Lifestyle 7. Spirituality |
| What are the levels of anxiety? | 1. mild 2. moderate 3. severe 4. panic |
| What does A&O x 3 mean? | Alert and oriented to person, place, time. |
| What factors should be considered when assessing sexuality? | Physical exam of genitals, Hx of self exams, Hx of STD's, Intimate relationships, Children |
| What is a normal venous stat? | 60-70% |
| When using the bell of the stethoscope, what kind of pressure should be used? | light |
| When using the diaphragm of the stethoscope, what kind of pressure should be used? | firm |
| T or F. The nurse should ask the client if they need to void before beginning a physical exam. | True. This will allow the client to be more relaxed and comfortable, and will allow the nurse to assess mobility. |
| What part of the body typically swells first? | feet |
| What are the markers for the anterior RUL? | the horizontal fissure from the fifth rib mid-axillary to the fourth rib |
| What are the markers for the anterior RLL? | to the right of the right oblique fissure from fifth rib mid-axillary line to the sixth rib midclavicular line |
| What are the markers for the anterior LUL? | the sixth rib midclavicular line marks the bottom border |
| The markers for the posterior RUL and LUL lung fields is ... | Above T3 |
| The markers for the posterior RLL and LLL lung fields is ... | From T3 to T10 |
| What is the best auscultation site for stridor? | either side of the trachea in apex of lungs |
| What organs are located in the RUQ? | Rt lobe of the liver, Gallbladder |
| What organs are located in the LUQ? | Spleen,Stomach, Lt kidney |
| What organs are located in the RLQ? | Appendix, Rt Ureter, Rt ovary and uterine tube in women |
| What quadrants is the large intestine located in? | ALL of the quadrants |
| What organs are located in LLQ? | Lt spermatic duct in men |
| A nurse auscultates odd sounds in the abdomen. What will the physician most likely do? | Order x-rays |
Created by:
tiffiny090180
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