Chapter 21

Question 0

Albumin (ALB)

Answer 0

3.4-5.4 (g/dL)

Question 1

Alkaline phosphate (ALP)

Answer 1

44-147 (IU/L)

Question 2

What to look for when preparing to listen to heart sounds

Answer 2

pacemaker or central-line port

Question 3

PMI

Answer 3

Fifth intercostal space, left midclavicular line. located over the apex of the left ventricle.

Question 4

First heart sound

Answer 4

S1, systolic sound, louder, Lubb

Question 5

Apical pulse (AP) is assessed for

Answer 5

rate, rhythm, and strength

Question 6

pulse deficit

Answer 6

when the radial pulse is slower than the apical pulse

Question 7

The order to assess the abdomen

Answer 7

1. inspect 2. auscultate 3. palpate 4. percuss

Question 8

inspect abdomen for

Answer 8

shape, and size. note if flat, rounded, or distended

Question 9

order of auscultation of bowel sounds

Answer 9

right lower quadrant (RLQ), right upper quadrant (RUQ), left upper quadrant (LUQ), left lower quadrant (LLQ)

Question 10

peristalsis

Answer 10

(click or gurgle sounds) wave-like muscular contractions of the intestines that moves intestinal contents to be eliminated via the rectal

Question 11

active bowel sounds

Answer 11

between 5 and 30 clicks or gurgles per minute in each of the 4 quadrants

Question 12

hypoactive bowel sounds

Answer 12

less than 5 clicks or gurgles per minute in any quadrant.

Question 13

hypoactive bowel sounds can be caused by?

Answer 13

slowed peristalsis, opioids, anesthesia, bedrest, decreased physical activity, infection in the peritoneal cavity, and bowel obstruction

Question 14

Three Levels of Physical Assessment

Answer 14

Comprehensive, focused, initial head-to-toe

Question 15

comprehensive health assessment

Answer 15

involves in-depth assessment of the whole person including physical, mental, emotional, cultural, and spiritual aspects of the pt’s health

Question 16

focused assessment

Answer 16

involves an examination and an interview regarding a specific body system

Question 17

initial head-to-toe assessment

Answer 17

a quick overall assessment of the pt’s condition to establish a baseline against which you will compare later assessments

Question 18

sequence of a system assessment

Answer 18

neurological, cardiovascular, respiratory, integumentary, gastrointestinal, genitourinary, muscular, skeletal

Question 19

initial head-to-toe shift assessment includes

Answer 19

vital signs including pain and SpO2, appearance, speech, safety risk factors, tubes and equipment, comfort or complaints, needs

Question 20

times to perform assessments

Answer 20

on admission (in -depth), at the beginning of each shift (focused), when pt condition changes, when evaluating the effectiveness of nursing care, any time things do not feel right

Question 21

Ascites

Answer 21

Accumulation of fluid in the peritoneal cavity. Assessment during palpation

Question 22

Palpation

Answer 22

The application of your hands to the external surfaces of the body to detect abnormalities of the skin or tissues lying below the skin.

Question 23

Palpation detections

Answer 23

Skin turgor
Growths on or below the skin
Edema
Size and location of body parts
Distention of the bladder or abdomen
Firmness -vs- softness of tissue
location and strength of pulses
Temp, texture, and moisture of the skin
Pain

Question 24

Inspection

Answer 24

The visual observation of anything about the body that you can see with the naked eye or with the assistance of other equipment such as a penlight, otoscope, or ophthalmoscope.

Question 25

Penlight

Answer 25

Used for the assessment of pupil constriction of the eyes and examination of the oral and nasal mucous membranes.

Question 26

Otoscope

Answer 26

Used to inspect the lining of the nose, tympanic membranes, and ear canals.

Question 27

Opthalmoscope

Answer 27

Used to assess the internal structures of the eyes.

Question 28

Times that assessment of weight and height may be ordered include.

Answer 28

For a newborn infant For assessment of nutritional or growth status for assessment of dehydration or fluid excess To determine the effectiveness of diuretic meds Calculation of certain medication dosages

Question 29

Percussion

Answer 29

Technique used least for assessment. Involves striking body parts with the tips of the fingers.

Question 30

Percussion Detection

Answer 30

:Elicit sounds that can help locate and determine the size of structures beneath the surface. : Identify whether the structure is solid or hollow : Detect areas containing air or fluid : Detect the size of the liver, and to identify lungs that are chronically hyperinflated due to disease : Detect urinary bladder distention and periotoneal ascites.

Question 31

Blunt percussion

Answer 31

Uses the fist rather than the finger to tap. Useful to detect tenderness of the kidneys.

Question 32

Auscultation

Answer 32

Listening to the sounds produced by the body. Some with the naked ear, such as belching, passing flatus or rectal gas, wheezing or gurgling, and loud bowel sounds.

Question 33

Eructation

Answer 33

Belching

Question 34

Stethoscope is used to

Answer 34

Assess the typically quieter sounds mad by the heart, lungs, intestinal tract, and arteries of the neck

Question 35

Olfaction

Answer 35

Sense of smell, is used to detect odors of different health problems.

Question 36

Neurological Components Assessed

Answer 36

``` Vital signs and level of consciousness Orientation Facial symmetry Pupillary size and reaction Ability to follow simple commands Speech Hand grip Feet flexion ```

Question 37

Hypothermia in a newborn

Answer 37

May identify that the infant is not yet able to regulate body temperature. It can also be a sign of sepsis or severe hypothyroidism, or be a result of trauma.