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health assessment Test 1 > Chapter 6 * > Flashcards

Chapter 6 * Flashcards

1
Q

Palpation

A

the skill of assessing the client through the sense od touch to determine specific characteristics of the body.

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2
Q

size, shape, location, mobility of a part, position, vibrations, temperature, texture, moisture, tenderness and edema can be assess during_________.

A

palpation

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3
Q

what is inspection?

A

the skill of observing the client in deliberate, systematic manner.

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4
Q

what does the nurse look for while inspecting a client?

A

Color, size, shape, contour, symmetry, movement or drainage..

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5
Q

what are the four basic or cardinal techniques to obtain subjective data?

A

inspection, palpation, percussion and auscultation

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6
Q

what are the parts of the hand that is the most responsive to the body structures and functions?

A

fingertips, finger pads, base of the fingers, palmar surface of the fingers, and the dorsal and ulnar surfaces of the hand

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7
Q

what are the finger pads commonly used for during palpation?

A

to discriminate the underlying structures and functions such as pulse, superficial lymph nodes or crepitus.

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8
Q

what is fremitus

A

vibratory tremors felt through the chest wall

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9
Q

how can fremitus be felt?

A

when using the base of the fingers (metacarpophalangeal)

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10
Q

what are the palmar aspect of the finger used for?

A

To determine position, consistency, texture, size of structures, pain and tenderness.

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11
Q

The dorsal surface if the fingers is most sensitive to_________________.

A

temperature

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12
Q

The ulnar surface of the hand including the finger is most sensitive to this type of vibrations?

A

fremitus

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13
Q

when is light palpation used?

A

to assess surface characteristics such as skin texture; pulse or tender, inflamed area near the surface of the skin.

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14
Q

how is light palpation assess?

A

the finger pads of the dominant hand are placed on the surface of the area to be examined. the hand is moved slowly, and the fingers pads at a depth of 1 cm, form circles on the skin.

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15
Q

what is moderate palpation?

A

the used of moderate pressure to determine depth, size, shape, consistency and mobility of organs as well as any pain, tenderness, or pulsations.

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16
Q

when is Deep palpation used?

A

to palpate or feel an organ that lies deep within a body cavity such as kidney, liver, or spleen. it is also used when underlying musculature is thick, tense, or rigid such as in obesity or with abnormal guarding.

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17
Q

what is an indicator of pathology while deep palpation?

A

involuntary guarding or rigidity, especially in the abdomen commonly accompanied with pain.

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18
Q

what is percussion?

A

“to strike through” strikes through a body part with an object, fingers or reflex hammer to produce sound or sound waves.

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19
Q

what are the 3 techniques of percussion?

A

direct, blunt, and indirect.

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20
Q

what is direct percussion?

A

the technique of tapping the body with the fingertips of the dominant hand. is commonly used to examine the thorax of an infant and to assess sinuses of an adult.

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21
Q

what is blunt percussion?

A

the placement of the palm of the non-dominant hand flat against the body surface and striking the nondominant hand with the dominant hand.

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22
Q

what is indirect percussion?

A

produces sounds that are clear and easy to interpret.

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23
Q

Define Plexor

A

an object that strikes the body to produce sound such as a hammer or tapping fingers.

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24
Q

Define Pleximeter

A

“measure” a device that accepts the tap or blow from a hammer.

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25
Q

what are the five percussion sounds?

A

Tympany, resonance, hyperresonance, dullness, and flatness.

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26
Q

Define tympany

A

loud high-pitch characteristic of an organ filled with air” commonly over gastric bubble in the stomach

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27
Q

Define resonance

A

a loud low pitched hollow tone of long duration. normal finding over the lungs.

28
Q

Define Hyperresonance

A

abnormally loud, low tone of longer duration usually heard when air is trapped in the lungs.

29
Q

Define Dullness

A

a high-pitched tone that is soft and of short duration, usually heard over solid body organs such as the liver or a stool-filled colon

30
Q

Define Flatness

A

high-pitched tone, very soft and of very short duration. occurs over solid tissue such as muscle or bone.

31
Q

what are the 4 characteristics of percussion sounds?

A

Intensity-or amplitude that refers to the softness or loudness of the sound.

pitch- or frequency of the sound refers to the number of vibrations of sound per second

duration- the length of time of the produced sound

quality- recognizable overtones produced by vibration. clear, hollow, muffled or dull.

32
Q

what is auscultation?

A

the skill is listening to the sounds produced by the body. “ sounds are described in terms of intensity, pitch, duration and quality”

33
Q

Stethoscope is used to?

A

it is used to auscultate body sounds such as blood pressure, hearth sounds, respirations, and bowel sounds.

34
Q

Doppler ultrasonic stethoscope uses

A

uses ultrasonic waves to detect sounds that are difficult to hear with regular stethoscope such as fetal heart sounds and peripheral pulses that cannot be easily palpated.

35
Q

when are the Doppler high pitched intensified

A

when the listener is close to the source of sound.

36
Q

what is an ophthalmoscope used for?

A

to inspect the internal eye structures.

37
Q

what is the purpose of an otoscope?

A

to inspect external ear structures

38
Q

what are Cues

A

bits of information that hint at the possibility of a health problem.

39
Q

what should the nurse due to provide a safe and comfortable environment?

A
  • provide privacy and warmth by using drapes
  • individualized according to the clients personal values and beliefs.
  • ensure that the examination room is warm.
  • never attempt to influence or coerce the client to agree to any procedure.
  • consider the client’s age, health status, level of functioning, and severity of illness at all times and adapt the examination accordingly.
40
Q

what should the nurse do before beginning a physical assessment?

A

wash hands in presence of the client.

41
Q

what are some accommodations that should be made for obese people?

A
  • extra-large examination gowns.
  • avoid placing patient on back due to weight on chest could inhibit deep breathing
  • chair in the waiting room must be wide and sturdy.
  • examination tables should be wide and sturdy with hand bars or footstools to help the client move onto the table.
42
Q

what are the Standard precautions

A
  • Hand washing.
  • use of gloves.
  • use of protective barriers.
  • disposal of sharps.
  • cleaning of equipment after use.
  • handling of specimens.
  • proper disposal of body wastes.
43
Q

what are the 3 part of a stethoscope

A

binaurals- earpiece

Flexible tubing- thick flexible and as short as possible (long tubing may distort the sound)

end piece- contains diaphragm and the bell is best for transmitting high-pitched sounds such as lung sounds and normal heart sounds. the Deep hollow end piece called the bell detects low-frequency sounds such as heart murmurs

44
Q

apertures of ophthalmoscope

A 
Large aperture
small aperture
red-free filter
grid
slit
45
Q

what are some examples of Cues a nurse should be able to recognize?

A

swelling (edema), Bruising, grimacing, guarding or wincing, odor, asymmetry of facial expression.

46
Q

why is it important for the nurse to explain each step in advance during an assessment?

A
  • to help the client relax and encourage participation of the client during the procedure.
  • to provide teaching
  • to enhance the clients understanding and give a sense of partnership.
47
Q

True/False Palpation proceeds any other assessment skills

A

False. Inspection does

48
Q

Inspection begins with a survey of the client’s appearance and comparison of the right and left side of the client’s body, which should be nearly ____.

A

Symmetric.

49
Q

What is a doppler ultrasonic stethoscope used for?

A

To obtain readings of blood pressure, pulse, and fetal heart rates.

50
Q

What is the name of the equipment that is used to dilate nares for inspection of the nose?

A

Nasal speculum

51
Q

An ophthalmoscope is used to …

A

Inspect the interior structures of the eye.

52
Q

To inspect the tyrannic membrane and external ear canal you would use what instrument?

A

Otoscope

53
Q

A sphygmomanometer is used to measure…

A

The circumference of the head, abdomen, and extremities.

54
Q

A stethoscope is used to…

A

Auscultate body sounds.

55
Q

What are the three parts of the stethoscope?

A
  • Binaurals (earpieces)
  • Flexible tubing
  • The end piece
56
Q

The end piece of the stethoscope contains…

A

The diaphragm and the bell

57
Q

To be effective in blocking out environmental noise, the binaurals should fit…

A

Snugly but comfortably, sloping forward, toward the nose, to match the natural slope of the ear canals.

58
Q

The tubing of the stethoscope joins the ___ and the ___.

A

Binaurals to the diaphragm

59
Q

The flat end piece, called the ___, screens out low pitched sounds and, therefore, is best for transmitting high pitched sounds such as lung sounds and normal heart sounds.

A

Diaphragm

60
Q

The deep hollow end piece, called the ___, detects low-frequency sounds such as heart murmurs.

A

Bell

61
Q

When performing physical assessment, the nurse will utilize four basic techniques to obtain objective and measurable data. These techniques are…

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
62
Q

Throughout the physical assessment, the professional nurse is required to apply __ ____ of ____

A

the principles of asepsis

63
Q

____ __ ___ ____ and ____ ____ and ____ ____ have provided guidelines to protect the clients and healthcare

A

Centers for Disease controls and OSHA Occupational Safety and Health Administration

64
Q

7 things a nurse can do/ will do/ or has to do as standard procautions

A
  1. hand washing
  2. use of gloves
  3. use of protective barriers
  4. disposal of sharps
  5. cleaning of equipment after use
  6. handling specimens disposal
  7. disposal of body wastes
65
Q

what are the 4 parts of inspection?

A
  1. Percussion
  2. Palpation
  3. Auscultation
  4. Smell

health assessment Test 1 (10 decks)

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