Health Assessment And Physical Examination

Question 1

two types of data

Answer 1

subjective and objective

Question 2

what the patient tells us about their world is what type of data

Answer 2

subjective

Question 3

where nurse has results and data/vital signs is what type of data ____

Answer 3

objective

Question 4

what are the methods of data collection?

Answer 4

interview, nursing health history, physical examination, and diagnostics/lab results

Question 5

interview has 3 phases

Answer 5

orientation phase, working phase, and termination phase

Question 6

types of physical assessment are ___

Answer 6

comprehensive, focused, system specific, and ongoing

Question 7

head to toe, normal assessment is ___

Answer 7

comprehensive

Question 8

if you have already done comprehensive, and going back to check on one area

Answer 8

focused

Question 9

system specific

Answer 9

similar to focused

Question 10

patient comes in often, do head to toe but assess the ongoing issues

Answer 10

ongoing

Question 11

what’s been going on is the ____

Answer 11

baseline history

Question 12

vital signs, inspection (looking), ausculation (listening), and palpation (feel) is what part of the assessment

Answer 12

examination

Question 13

how do you assess a patient?

Answer 13

look, listen, feel

Question 14

nursing process and physical assessment is done in what order?

Answer 14

assessment, outcome identification, planning, implementation, and evaluation

Question 15

good lighting, expose all of part to be examined, use penlight for ears, eyes, and mouth. observe for color, shape/symmetry, position and movement is what technique of the assessment?

Answer 15

inspection

Question 16

touch is what technique of assessment?

Answer 16

palpation

Question 17

light palpation is how many cm or inch in depth?

Answer 17

1 cm or 0.5 inch

Question 18

deep palpation is how many cm or inch in depth?

Answer 18

4 cm or 2 inch

Question 19

listen, frequency (# of oscillations/sound waves) per second generated by vibrating object, loudness (amplitude of a sound wave), quality (descriptive), duration (length of time that sounds last- short, medium, long)

Answer 19

auscultation

Question 20

smell, abnormal or normal

Answer 20

olfaction

Question 21

_____ typically taken prior to exam and begin with general survey

Answer 21

health history

Question 22

_____ is the single most important assessment component and often first clue of deteriorating conditon

Answer 22

level of conciousness

Question 23

how do you test level of consciousness?

Answer 23

alert, lethargic, obtunded, stuporous/semi-comatose, and comatose

Question 24

attentive, follows commands, if asleep-wakes up promptly and remains attentive

Answer 24

alert (LOC)

Question 25

drowsy but awakens, slow to respond

Answer 25

lethargic

Question 26

difficult to arouse, needs constant stimulation

Answer 26

obtunded

Question 27

arouses only to vigorous/noxious stimuli, may only withdraw from pain

Answer 27

stuporous/semi-comatose

Question 28

no response to verbal or noxious stimuli, no movement

Answer 28

comatose

Question 29

pt oriented to person, place, and town, also known as mentation

Answer 29

cognitive awareness

Question 29

how do you test cognitive awareness?

Answer 29

name, DOB, where are they right now, what year/day it is, and what brought you in

Question 29

PERLA is testing on what cranial nerves?

Answer 29

cranial nerves III, IV, and VI

Question 30

examine size and shape of pupils and compare to scale

Answer 30

pupil response

Question 31

PERLA stands for _____

Answer 31

pupils, equal, react to, light, and accommodation

Question 32

using the tip of unlit penlight and have pt follow with eyes only and about 9-12 inches from face in "H" motion is called ____

Answer 32

cardinal gaze

Question 33

ask patient to smile and show teeth, wrinkle forehead or raise eyebrows, looking for symmetry is testing what cranial nerves

Answer 33

cranial nerve VII

Question 34

ask patient to touch roof of mouth with tongue, protrude tongue out of mouth and side to side is testing what cranial nerve?

Answer 34

cranial nerve XII

Question 35

place hands on patient shoulders lightly and ask pt to shrug shoulders is testing what cranial nerve?

Answer 35

cranial nerve XI

Question 36

BUE means

Answer 36

bilateral upper extremities

Question 37

BLE means

Answer 37

bilateral lower extremities

Question 38

crackles or rales, rhonchi, wheezes, and pleural friction rub are what?

Answer 38

abnormal or adventitious sounds of lungs

Question 39

can be fine or course at the base of the lungs-high pitching popping sounds

Answer 39

crackles or rales

Question 40

can be cleared with coughing typically, over the trachea and bronchial area (wet sounds ,roaring)

Answer 40

rhonchi

Question 41

airways get restricted/narrowed, air passing through the tube fast

Answer 41

wheezes

Question 42

lining around lungs and has fluid here, if lining gets dry, it is rubbing tissue on tissue

Answer 42

pleural friction rub

Question 43

abnormally slow, under 12 RR

Answer 43

bradypnea

Question 44

greater than 20

Answer 44

tachypnea

Question 45

absence of respirations, no respirations or period of apnea

Answer 45

apnea

Question 46

high respirations

Answer 46

hyperpnea

Question 47

rapid, deep breathing at a constant rate

Answer 47

kussmaul's

Question 48

depth and rate are irregular with periods of apnea

Answer 48

cheyne-stokes

Question 49

anterior and posterior lung sounds and clubbing of fingers

Answer 49

respiratory components of assessment

Question 50

systole or S1 and is the sound associated with the closing of the mitral/tricuspid valves

Answer 50

"LUB" sound

Question 51

diastole or S2 and is the sound associated with the closing of the aortic/pulmonic valves

Answer 51

"DUB" sound

Question 52

when is there a longer pause between what heart sounds?

Answer 52

S2 and S1

Question 53

location of the heart sounds

Answer 53

aortic, pulmonic, tricuspid, and mitral

Question 54

aortic location

Answer 54

right base, second intercostal space to the right of the sternal border

Question 55

pulmonic location

Answer 55

left base, second intercostal space to the left of the sternal border

Question 56

tricuspid location

Answer 56

left lateral sternal border, 5th intercostal space to the left of the sternal border

Question 57

mitral location

Answer 57

midclavicular line at the 5th intercostal space

Question 58

swelling in the extremities is ____

Answer 58

edema

Question 59

most often on feet and ankles, older adults and standing

Answer 59

dependent edema

Question 60

venous insufficiency or heart failure; fluid in tissues

Answer 60

pitting edema

Question 61

heart sounds, cartoid pulses, radial pulses, pedal pulse, capillary refill, assess for edema

Answer 61

cardiac components of assessment

Question 62

neck ROM, BUE ROM, BLE ROM, HGTW, flexion/extension BUE/BLE are ____

Answer 62

musculoskeletal components of assessment

Question 63

hydration, temperature, color, texture, rashes, lesions and cracking are assessment of ___

Answer 63

skin

Question 64

pale or ashen gray

Answer 64

pallor

Question 65

redness r/t vasodilation (a lot of blood flow to area)

Answer 65

erythemea

Question 66

yellow, impaired liver (can see in sclera of eye)

Answer 66

juandice

Question 67

bluish, decreased circulation or oxygenation of blood

Answer 67

cyanosis

Question 68

____ test is elasticity of skin related to hydration

Answer 68

turgor

Question 69

caused by kidney or heart failure and leads to excess fluid collection in skin tissue

Answer 69

pitting edema

Question 70

nails should be ____

Answer 70

transparent, smooth, rounded, convex, and hygienic

Question 71

patent nares means:

Answer 71

the nostrils are open

Question 72

excretion of waste products from kidneys and intestines

Answer 72

elimination

Question 73

process of elimination waste

Answer 73

defecation

Question 74

semisolid mass of fiber, undigested food, inorganic matter

Answer 74

feces

Question 75

observe size, shape, contour, skin integrity of abdomen

Answer 75

inspection

Question 76

bowel size, four quadrants, normal hypoactive, hyperactive- start in RLQ, RUQ, LUQ, LLQ

Answer 76

auscultation

Question 77

palpate for tenderness, pain, and masses of the abdomen

Answer 77

palpation

Question 78

inability to control urine or feces

Answer 78

incontinence

Question 79

to urinate

Answer 79

void

Question 80

to urinate

Answer 80

micturate

Question 81

painful or difficult urinating

Answer 81

dysuria

Question 82

blood in the urine

Answer 82

hematuria

Question 83

frequent night urination

Answer 83

nocturia

Question 84

large amounts of urine

Answer 84

polyuria

Question 85

voiding at intervals

Answer 85

urine frequency

Question 86

the need to void all at once

Answer 86

urinary urgency

Question 87

presence of large protein in urine

Answer 87

proteinuria

Question 88

leakage of urine despite voluntary control of urination

Answer 88

dribbling

Question 89

accumulation of urine in bladder without the ability to completely empty

Answer 89

retention

Question 90

urine remaining post void >100 mL

Answer 90

residual

Question 91

primary regulators of fluid and acid-base balance

Answer 91

kidneys

Question 92

tubule structures that enter into the bladder

Answer 92

ureters

Question 93

urine traveling through ureters is typically _____

Answer 93

sterile

Question 94

ureters enter bladder ____ & ______ to prevent reflux

Answer 94

obliquely and posteriorly

Question 95

in women the uretha is short, ___ to ____ inches

Answer 95

1.5 inches to 2.5 inches

Question 96

in men, the uretha is ___ inches, serves in both the GI and reproductive systems

Answer 96

8 inches

Question 97

in men, the ____ lies against the anterior wall of rectum

Answer 97

bladder

Question 98

in women, the ___ rest against anterior walls of uterus and vagina

Answer 98

bladder

Question 99

normal bladder is ____ mL

Answer 99

500

Question 100

bladder can extend to ____ mL

Answer 100

1000

Question 101

What are normal sounds of the lungs?

Answer 101

Vesicular, bronchovesicular, and bronchial

Question 102

Filter and regulate, remove waste from blood to form urine

Answer 102

Kidneys

Question 103

Transport urine from kidneys to bladder

Answer 103

Ureters

Question 104

Reservoir for urine until the urge develops

Answer 104

Bladder

Question 105

Urine travels from bladder and exits through urethral meats

Answer 105

Urethra