Health Assessment Lecture 2

Question 1

Assessing a client’s health status is a major component of
nursing care and has three aspects:

Answer 1

(a) the nursing health history
(b) the physical assessment, and
(c) diagnostic testing

Question 2

A ??? is conducted in a systematic and efficient manner starting at the head and proceeding downward
(head- to-toe assessment)

Answer 2

complete health assessment

Question 3

cephalocaudal

Answer 3

head to toe

Question 4

child development

Answer 4

proximal to distal, head to toe

Question 5

Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface

Answer 5

dorsal recumbent

Question 6

Back-lying position with legs extended; with or without pillow under the head

Answer 6

supine (horizontal recumbent)

Question 7

A seated position, back unsupported and legs hanging freely

Answer 7

sitting

Question 8

Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table

Answer 8

lithotomy

Question 9

Side-lying position with lowermost arm behind the body, uppermost leg flexed a hip and knee, upper arm flexed at shoulder and elbow

Answer 9

sims

Question 10

Lies on abdomen with head turned to the side, with or without a small pillow

Answer 10

prone

Question 11

should be arranged so that the area to be assessed is exposed
and other body areas are covered.

Answer 11

Drapes

Question 12

are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination.

Answer 12

The pads of the fingers

Question 13

is the visual assessment; that is, assessing by using the sense
of sight or vision.

Answer 13

Inspection

Question 14

is the examination of the body using the sense of touch.

Answer 14

Palpation

Question 15

There are two types of palpation:

Answer 15

light and deep

Question 16

should always precede deep palpation because heavy pressure on the fingertips can dull the sense of touch

Answer 16

Light palpation (superficial palpation)

Question 17

type of palpation that is usually not done during a routine examination and requires significant practitioner skill

Answer 17

Deep

Question 18

is done with one hand or with two. The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensations

Answer 18

Deep palpation

Question 19

is the act of striking the body surface to elicit sounds that
can be heard or vibrations that can be felt

Answer 19

Percussion

Question 20

There are two types of percussion:

Answer 20

direct and indirect

Question 21

the nurse strikes the area to be percussed directly with the pads of the fingers.

Answer 21

direct percussion

Question 22

is the striking of a finger (usually the middle finger) held against the body area to be assessed

Answer 22

Indirect percussion

Question 23

Percussion elicits five types of sound

Answer 23

flatness
dullness
resonance
hyperresonance
tympany

Question 24

is an extremely dull sound produced by very dense tissue such
a muscle or bone.

Answer 24

Flatness

Question 25

is a thudlike sound produced by dense tissue such as the liver, spleen or heart.

Answer 25

Dullness

Question 26

is a hollow sound such as that produced by lungs filled with air

Answer 26

Resonance

Question 27

is not produced in the normal body. It is described as booming and can be heard over an emphysematous lung.

Answer 27

Hyperresonance

Question 28

is a musical or drumlike sound produced from an air-filled stomach.

Answer 28

Tympany

Question 29

is the process of listening to sounds produced within the body

Answer 29

Auscultation

Question 30

??? auscultation by listening to body sounds with the unaided ear

Answer 30

direct

Question 31

??? auscultation by using a stethoscope

Answer 31

indirect

Question 32

is the number of vibrations per second (frequency)

Answer 32

The pitch

Question 33

refers to the loudness or softness of a sound

Answer 33

The intensity (amplitude)

Question 34

? of a sound is its length (long or short).

Answer 34

The duration

Question 35

is a subjective description of a sound, for example, whistling, gurgling, or snapping

Answer 35

The quality of sound

Question 36

Sequence to conduct Physical Assessment

Answer 36

general survey head neck

Question 37

general survey

Answer 37

appearance and mental status vital signs height and weight

Question 38

are measured (a) to establish baseline data against which measurements and (b) to detect actual and potential health problems.

Answer 38

vital signs

Question 39

Measuring the ??? and ??? provides important assessment data on the client’s general health status.

Answer 39

weight and height

Question 40

If the client is a child under the age of 2 years, measure height in the ??? position with knees fully extended.

Answer 40

supine

Question 41

The skull is made up of many bones, namely:

Answer 41

frontal, parietal, occipital, mastoid process, mandible, maxilla, and zygomatic.

Question 42

(the degree of detail the eye can determine in an image)

Answer 42

visual acuity

Question 43

(the area an individual can see when looking straight ahead

Answer 43

visual fields

Question 44

The ear is divided into three parts:

Answer 44

external ear, middle ear, and inner ear

Question 45

A nurse passages can inspect the nasal very simply with a

Answer 45

flashlight or a penlight

Question 46

includes inspection and palpation of the external nose; patency of the nasal cavities; and inspection and palpation of the facial sinuses

Answer 46

Assessment of the nose

Question 47

The ??? are composed of a number of structures: lips, inner and buccal mucosa, the tongue and floor of the mouth, teeth and gums, hard and soft palate, uvula, salivary glands, tonsillar pillars, and tonsils.

Answer 47

mouth and oropharynx

Question 48

The nurse inspects and palpates the client’s mouth and oropharynx using a ???. However, detailed assessment is usually performed by an expert such as the ???.

Answer 48

penlight; dentist

Question 49

includes the muscles,lymph nodes, trachea, thyroid gland, carotid arteries, and jugular veins.

Answer 49

examination of the neck

Question 50

areas of the neck are defined by the

Answer 50

sternocleidomastoid muscles

Question 51

sternocleidomastoid muscles divide each side of the neck into 2 triangles:

Answer 51

anterior & posterior

Question 52

The trachea, thyroid gland, anterior cervical nodes, and carotid artery lie within the ??? triangle.

Answer 52

anterior

Question 53

The greatest number of lymph nodes are located in the ???

Answer 53

head and neck.