Fundamentals: Chapter 30

Question 1

What does a complete health assessment involve?

Answer 1

nursing history and behavioral and physical examination

Question 2

When should you perform a reassessment?

Answer 2

when a patient’s condition changes as it improves or worsens

Question 3

What are the two types of palpation used for a physical examination?

Answer 3

light and deep

Question 4

What involves tapping the skin with the fingertips to vibrate underlying tissues and organs?

Answer 4

percussion

Question 5

What involves listening to sounds the body makes to detect variations from normal?

Answer 5

auscultation

Question 6

What is important to remember when assessing skin pallor on a dark-skinned patient?

Answer 6

normal brown skin appears to be yellow-brown and normal black skin appears to be ashen gray

Question 7

What is the best site to assess for jaundice?

Answer 7

sclera

Question 8

What is the term for red discoloration?

Answer 8

erythema

Question 9

What refers to the character of the skin and how the deeper layers feel?

Answer 9

skin texture

Question 10

What is induration?

Answer 10

hardening

Question 11

What refers to the elasticity of the skin?

Answer 11

turgor

Question 12

What is the term for when pressure from an examiners fingers leave an indentation in the edematous area?

Answer 12

pitting edema

Question 13

What are the most common neoplasms in patients?

Answer 13

skin (cutaneous) malignancies

Question 14

What is the most common carcinoma in sun-exposed areas and frequently occurs with a history of sun-damaged skin?

Answer 14

Basal cell carcinoma

Question 15

Which carcinoma develops on the outer layers of sun-exposed skin?

Answer 15

Squamous cell carcinoma

Question 16

Which skin cancer develops from melanocytes and often begins as a mole?

Answer 16

malignant melanoma

Question 17

What does ABCD stand for when assessing the skin for any type of carcinoma?

Answer 17

Asymmetry

Border irregularity

Color

Diameter

Question 18

What are the two types of hair that cover the body?

Answer 18

soft, fine, vellus hair, which covers the body; and coarse, long, thick terminal hair, which is easily visible on the scalp, axillae, and pubic areas and in the beard on men

Question 19

What is a change in angle between nail and nail base

Answer 19

clubbing

Question 20

What are transverse depressions in nails indicating temporary disturbance of nail growth

Answer 20

Beau’s lines

Question 21

What is a concave curve in a nail?

Answer 21

Koilonychia (spoon nail)

Question 22

What are red or brown linear streaks in the nail bed?

Answer 22

splinter hemorrhages

Question 23

What is inflammation of the skin at the base of the nail?

Answer 23

Paronychia

Question 24

What does an examination of the head and neck include?

Answer 24

assessment of the head, eyes, ears, nose, mouth, pharynx, and neck

Question 25

What does an examination of the eyes include?

Answer 25

assessment of visual acuity, visual fields, extraocular movements, and external and internal eye structures

Question 26

What is an involuntary, rhythmical oscillation of the eyes

Answer 26

nystagmus

Question 27

What is responsible for tear production?

Answer 27

lacrimal gland

Question 28

What is a thin white ring along the margin of the iris? When is it uncommon?

Answer 28

arcus senilis under 40 yrs old

Question 29

What does an observation of the pupils include?

Answer 29

size, shape, equality, accommodation, and reaction to light

Question 30

What do cloudy pupils indicate?

Answer 30

cataracts

Question 31

What do dilated pupils result from?

Answer 31

glaucoma, trauma, neuro disorders, eye medication, withdrawal from opioids

Question 32

What do constricted pupils indicate?

Answer 32

inflammation of the iris, drug use

Question 33

What does pinpoint pupils indicate?

Answer 33

opioid intoxication

Question 34

What can alter pupillary reaction?

Answer 34

changes in intracranial pressure, lesions along the nerve pathways, locally applied ophthalmic medications, and direct trauma to the eye

Question 35

What kind of nurse uses an ophthalmoscope to inspect the internal eye structures?

Answer 35

APRN

Question 36

What does an ear assessment involve?

Answer 36

the integrity of ear structures and hearing acuity

Question 37

How does a nurse assess the integrity of the nose and sinuses?

Answer 37

inspection and palpation

Question 38

What is the purpose of assessing the mouth and pharynx?

Answer 38

detect signs of overall health; determine oral hygiene needs; and determine therapies needed for patients with dehydration, restricted intake, oral trauma, or oral airway obstruction

Question 39

What does the assessment of the neck include?

Answer 39

assessing the neck muscles, lymph nodes of the head and neck, carotid arteries, jugular veins, thyroid gland, and trachea

Question 40

What does an abnormality of superficial lymph nodes sometimes reveal?

Answer 40

the presence of an infection or malignancy

Question 41

What are the vibrations in the chest wall created by sounds waves during speech called?

Answer 41

vocal or tactile fremitus

Question 42

What are the 3 normal breath sounds?

Answer 42

Vesicular Bronchovesicular Bronchial

Question 43

What are the 4 types of adventitious breath sounds?

Answer 43

crackles rhonchi wheezes pleural friction rub

Question 44

What is the failure of the heart to beat at regular successive intervals called?

Answer 44

dysrhythmia

Question 45

What is caused by a premature rush of blood into a ventricle that is stiff or dilated as a result of heart failure and hypertension

Answer 45

ventricular gallop

Question 46

What are are sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase

Answer 46

murmur

Question 47

What is a murmur that occurs between S1 and S2?

Answer 47

systolic murmur

Question 48

What is a murmur that occurs between S2 and the next S1?

Answer 48

diastolic murmur

Question 49

How do you assess for radiation when listening to the heart sounds?

Answer 49

listen over areas in addition to where it is heard best such as over the neck or back

Question 50

What is a continuous palpable sensation that resembles the purring of a cat?

Answer 50

thrill

Question 51

What is the term for vascular narrowing?

Answer 51

stenosis

Question 52

What is the blowing sound that is created by turbulence when blood passes through a narrowed section?

Answer 52

bruit

Question 53

What are the most accessible veins for examination?

Answer 53

internal and external jugular veins in the neck

Question 54

When does a nurse assess the lymphatic drainage of the lower extremities?

Answer 54

during examination of the vascular system or during the female or male genital examination

Question 55

How does a nurse assess the lymphatic drainage of the upper extremities?

Answer 55

gently palpate the epitrochlear nodes, located on the medial aspect of the arms near the antecubital fossa

Question 56

When is the best time for a breast self exam (BSE)?

Answer 56

the fourth through seventh day of the menstrual cycle or right after the menstrual cycle ends, when the breast is no longer swollen or tender from hormone elevations

Question 57

What does an abdominal assessment include?

Answer 57

assessment of structures of the lower gastrointestinal (GI) tract in addition to the liver, stomach, uterus, ovaries, kidneys, and bladder

Question 58

What is used for an objective measurement of consciousness?

Answer 58

Glasgow Coma Scale

Question 59

What are common pressure points?

Answer 59

Pinna, shoulder blades, elbows, sacrum and coccyx, knees, heels, toes

Question 60

What can cause increased GI motility?

Answer 60

Inflammation of the bowel, anxiety, diarrhea, bleeding, excessive ingestion of laxatives, and reaction of the intestines to certain foods

Question 61

What is the term for hyperactive GI sounds that are loud, “growling” sounds?

Answer 61

borborygmi