Physical Assessment

Question 1

Hyperresonance

Answer 1

loud, booming, low-pitched sound of longer duration found with over inflated air-filled tissue. Ex: pulmonary emphysema

Question 2

Resonance

Answer 2

moderate to loud, low pitched (clear, hollow) sound of moderate duration. Ex: normal lung

Question 3

Tympany

Answer 3

loud, drumlike, high-pitched or moderately long duration found with enclosed air-filled structures. Ex: bowel

Question 4

Dull

Answer 4

soft, muffled, moderate to high-pitched sound of short duration; found with dense, fluid-filled tissue (liver)

Question 5

Flat

Answer 5

very soft, high-pitched sound of short duration, found with very dense tissue. Ex: bone, muscle

Question 6

Normal RR Newborn

Answer 6

30-60

Question 7

Normal RR Kid

Answer 7

20-30

Question 8

Normal RR Adult

Answer 8

12-20

Question 9

Normal Rate Newborn

Answer 9

120-140

Question 10

Normal Rate Kid

Answer 10

70-140

Question 11

Normal Rate Adult

Answer 11

60-100

Question 12

Normal BP Newborn

Answer 12

65/41

Question 13

Normal BP Kid

Answer 13

90/55 - 110/65

Question 14

Normal BP Adult

Answer 14

120/80

Question 15

Oral Temp

Answer 15

98.6

Question 16

Anal Temp

Answer 16

99.6

Question 17

Axillary Temp

Answer 17

97.6

Question 18

Cranial Nerve #1

Answer 18

Olfactory: sense of smell. Have client smell a nonirritating substance.

Question 19

Cranial Nerve #2

Answer 19

Optic: sense of vision for clear (acute) vision near and distant. Test: snellen eye chart and ophthalmoscopic exam.

Question 20

Cranial Nerve #3

Answer 20

Oculomotor: pupil constriction, pupils equal in size and equally reactive to light. Test: penlight into eye, follow finger.

Question 21

Cranial Nerve #4

Answer 21

Trochlear: move eyes down and inward. Test: penlight into eye, follow finger.

Question 22

Cranial Nerve #5

Answer 22

Trigeminal: sensation of face and neck. Test: pin and cotton over forehead, cheek, and jaw; bite down with jaw.

Question 23

Cranial Nerve #6

Answer 23

Abducens: lateral movement of eyes. Test: penlight into eye, follow finger.

Question 24

Cranial Nerve #7

Answer 24

Facial: able to smile, wrinkle, and taste. Test: facial symmetry, close eyelids, and place substance on tongue.

Question 25

Cranial Nerve #8

Answer 25

Acoustic: hearing and balance. Test: Rinne, Webber, stand with eyes close.

Question 26

Cranial Nerve #9

Answer 26

Glossopharyngeal: gag reflex, ability to swallow and taste; stimulate gag reflex.

Question 27

Cranial Nerve #10

Answer 27

Vagus: able to swallow and speak. Test: say "ah" and observe uvula

Question 28

Cranial Nerve #11

Answer 28

Spinal accessory: able to flex and rotate head and shrug shoulders. Test: turn head against resistance.

Question 29

Cranial Nerve #12

Answer 29

Hypoglossal: move tongue side to side. Test: stick out tongue.

Question 30

Rinne Test

Answer 30

compares bone conduction with air conduction; vibrating tuning fork placed on mastoid process, when client no longer hears sound, position in front of ear canal. Normal: air greater by 2:1.

Question 31

Webber Test

Answer 31

assesses bone conduction; vibrating tuning fork placed in middle of forehead; normal sound heard equally in ears.

Question 32

Vesicular

Answer 32

soft and low pitched breezy, sounds over peripheral lung fields; inspiration.

Question 33

Bronchovesicular

Answer 33

medium-pitched, moderately loud over bronchi; inspiration = expiration

Question 34

Bronchial

Answer 34

loud, coarse, blowing sound heard over trachea; expiration is greater

Question 35

Crackles

Answer 35

rales; crackling or gurgling sounds that clear with coughing

Question 36

Rhonchi

Answer 36

musical sounds or vibrations commonly heard on expiration

Question 37

Wheeze

Answer 37

squeaky sounds heard during inspiration and expiration, narrowed airways

Question 38

Pleural friction rub

Answer 38

grating sound or vibration heard during inspiration and expiration

Question 39

Aortic

Answer 39

right 2nd intercostal

Question 40

Pulmonic

Answer 40

left 2nd intercostal

Question 41

Erb's Point

Answer 41

3rd instercostal space left of sternum

Question 42

Tricuspid area

Answer 42

4th intercostal space

Question 43

Mitral area

Answer 43

5th intercostal space

Question 44

Point of Maximal impulse

Answer 44

impulse of the left ventricle felt most strongly, located at left intercostal space in the midclavicular line

Question 45

SI

Answer 45

"lubb" closure of tricuspid and mitral valves; dull and low pitched, onset of systole, louder at apex

Question 46

S2

Answer 46

"dubb" closre of aortic and pulmonic valves, onset of diastole, loudest at base

Question 47

Murmurs

Answer 47

abnormal sounds caused by turbulence within a heart valve; in a vessel, its a bruit