Chapter 12 Physical Assessment

Question 1

SYMPTOMS
________ full description by the patient of the onset ( when did it start?), the course, the character of the problem, and any factors that aggravate or alleviate.

Answer 1

Encourage

Question 2

DISEASE

It is any ____ of a structure or function of the body; a pathologic condition of the body.

Answer 2

Disturbance

Question 3

How are diseases recognized?

Answer 3

by a set of signs and symptoms

Question 4

Signs and symptoms are ___in groups to help the health care provider to make a medical diagnosis.

Answer 4

Clustered

Question 5

What are the origins of disease?

Answer 5

disease of illness originates from many causes; hereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, and environmental.

Question 6

A _____ factor is any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other that _____ the vulnerability of an individual or a group to illness or accident.

Answer 6

Risk

Increases

Question 7

Risk factors for developing a disease:

Answer 7

Genetic and physiologic, age, environment, and life style.

Question 8

Chronic

Answer 8

develops slowly and persists over a long period, often for a person’s lifetime.

Question 9

Remission

Answer 9

partial or complete disappearance of clinical and subjective characteristics of a disease.

Question 10

Acute

Answer 10

Begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment.

Question 11

Organic disease

Answer 11

results in structural change in an organ that interferes with its functioning

Question 12

Functional disease

Answer 12

may be manifested as organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities.

Question 13

Infection

Answer 13

caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites

Question 14

Inflammation

Answer 14

protective response of the body tissues to irritation, injury, or invasion by disease- producing organisms.

Question 15

Cardinal signs of infection and inflammation

Answer 15

Erythema, edema, heat, pain, purulent drainage, and loss of function.

Question 16

Assessment

Answer 16

process of making an evaluation or appraisal of the patient’s condition.

Question 17

Medical Assessment

Answer 17

physical examination is conducted by the health care provider
the nurse is often expected to carry out certain functions.

Question 18

Items needed to perform the nursing physical assessment

Answer 18

penlight, stethoscope, blood pressure cuff, thermometer, gloves, and a tongue blade.

Question 19

what is the purpose of the nursing physical assessment?

Answer 19

to determine the patients state of health or illness.

Question 20

What is the initial step of the nursing process and in forming the nursing care plan?

Answer 20

Nursing physical assessment

Question 21

When do you perform a physical assessment?

Answer 21

Perform as soon after admission as possible
Initial assessment is done by an RN
ongoing assessment is the responsibility of LPN and the RN

Question 22

Neurologic ( Head- to- toe assessment)

Answer 22

level of consciousness 
level of orientation 
hand grips 
vital signs 
glasgow coma scale

Question 23

Skin and hair ( Head- to- toe assessment)

Answer 23

Observe skin for color, temperature, moisture, texture, turgor, and evidence of injury or skin lesions.

note color of sclera, mucous membranes, tongue, lips, nail beds, palms and soles.

determine the quantity, quality, and distribution of hair

hair should be smooth, not oil or dry.

scalp should be free from dandruff, lesions, or parasites.

head and neck 
mouth and throat
eyes 
ears 
nose

Question 24

Chest, lungs, heart, and vascular system

Answer 24

inspect bilateral chest expansion 
note rate, depth of respirations
note audible sounds without stethoscope 
assess oxygen saturation 
breasts 
lung sounds
spine heart sounds 
peripheral vascular system

Question 25

Gastrointestinal system

Answer 25

abdomen

Question 26

Genitourinary system

Answer 26

inspect labia/ genitalia and pubic hair
palpate the scrotum 
palpate supra pubic area 
rectum 
legs and feet

Question 27

Documentation

Answer 27

Follow institution protocol and forms used for history and physical assessment be objective, clear, complete, and concise.

Question 28

Telephone consultation

Answer 28

Very important to follow HIPAA guidelines.

S O A P I E ( R)

Question 29

Cultural considerations

Answer 29

culture includes: knowledge, skill, art morals, law, customs, and any other acquired habits and capabilities of a group of people.

Question 30

How do you develop cultural and ethnic sensitivity?

Answer 30

Recognize that cultural and ethnic diversity exist
demonstrate respect for people as individuals
respect the unfamiliar