Physical Assessment- Exam 3

Question 1

Purpose of physical assessment?

Answer 1

Gather baseline data about the clients health
Supplement, confirm, or refute previous data
Make clinical judgments
Evaluate psychological outcomes of care 

Question 2

Types of data

Answer 2

Subjective and objective

Question 3

Sources of data

Answer 3

Primary and secondary

Question 4

Laboratory diagnostic test

Answer 4

ABGS, CBC, sputum

Question 5

Radiologic studies diagnostic test

Answer 5

Chest x-ray
CT
V/Q scan
PET scan

Question 6

Diagnostic tests

Answer 6

Skin test
Pulmonary function test
Endoscopy examinations

Question 7

Interview and the stages

Answer 7

Orientation phase
Working phase
Termination phase

Question 8

Types of physical assessment

Answer 8

Comprehensive
Focused
System specific
Ongoing

Question 9

Elements of assessment

Answer 9

History
Baseline history
Problem based history

Question 10

Assessment

Answer 10

Interview
Physical assessment

Question 11

Planning

Answer 11

Based on assessment data

Question 12

Process and the physical assessment

Answer 12

Assessment
> interview
> physical assessment
Nursing diagnosis
Planning
>based on assessment data
Evaluation
> establishes nursing accountability

Question 13

Techniques for assessment
All senses except for taste

Answer 13

Inspection
Palpation
Percussion
Auscultation
Olfaction

Question 14

Inspection of the patient (Visual)

Answer 14

Good lighting

Expose all of part to be examined, drape, or cover parts, not being examined for privacy

Use additional lighting/devices for some areas of body eyes, ears throat

Question 15

During inspection, observe for

Answer 15

Color
Shape/symmetry
Movement
Position

Question 16

Palpitation

Answer 16

Bimanual/manual technique

Dorsum of hand - assess body temp

Palm or ulnar surface of hand

Palmer surface of finger/finger pads

Question 17

Light palpation

Answer 17

1 cm or 1/2 depth

Question 18

Deep palpation

Answer 18

4cm or 2 in depth

Question 19

Palpate to assess

Answer 19

Texture
Resistance
Resilience
Mobility
Temperature
Thickness
Shape
Moisture

Question 20

Percussion- direct

Answer 20

Apply directly to body

Question 21

Percussion- indirect

Answer 21

 Applied through another surface

Question 22

Auscultation (auditory)

Answer 22

 Frequency
Loudness
Quality
Duration

Question 23

Auscultation- frequency

Answer 23

Number of oscillations per second generated by a vibrating object

Question 24

Auscultation- loudness

Answer 24

Amplitude of a sound wave

Question 25

Auscultation- quality

Answer 25

Descriptive

Question 26

Auscultation- duration

Answer 26

Length of time that sound last

Question 27

What part of the stethoscope is best for low pitch sounds Ex: vascular and some heart sound

Answer 27

Bell

Question 28

What part of the stethoscope is best for high pitch sounds Example: bowel and some abnormal lung sound

Answer 28

Diaphragm

Question 29

Olfactory -sense of smell

Answer 29

Used to detect abnormal versus normal Examples Alcohol on breath Foul smelling odor from wound sweet, smelling odor from mouth

Question 30

Preparing for the assessment

Answer 30

Gather all necessary equipment Introduce yourself Explain procedure Use gloves if necessary Wash hands before and after any contact with patient Clean stethoscope, head in blood pressure cuffs between patients Make patient comfortable and allow for privacy and confidentiality

Question 31

What general survey do we start with before we start assessment

Answer 31

Race/gender Age Body type Posture Signs of distress Substance abuse Speech Movement/gait Hygiene/grooming Dress Affect/mood Patient abuse

Question 32

Signs of abuse

Answer 32

Inconsistency between injury and statement Bruises, lacerations, burns, bites X-ray show fractures in various stages of healing Behavior, issues, insomnia, anxiety, isolation

Question 33

- most common in dependent lobes; right and left lung bases - fine crackles: are high pitched fine, short, interrupted cracking sounds - medium crackles: are lower, moister sounds heard during middle of inspiration; not cleared with cough - coarse crackles: are loud, bubbly sounds heard during inspirations or expiration, not cleared by coughing

Answer 33

Crackles

Question 34

Primarily heard over trachea and bronchi, if loud enough, able to heard over most lung fields Cause: muscular spasm, fluid or mucus in large airways, new growth or external pressure causing turbulence Loud low pitched rumbling, coarse sounds are heard either during inspiration or expiration, sometimes cleared by coughing

Answer 34

Rhonchi

Question 35

- heard all over lung fields - high velocity airflow through severely narrowed or obstructed airway - high pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration, usually louder on expiration

Answer 35

Wheezes

Question 36

- heard over anterior lateral lung field (if pt is sitting up) - inflamed pleura; partial pleura, rubbing against visceral pleura - dry rubbing or grating quality is heard during inspiration or expiration, does not clear with coughing; heard loudest over lower lateral anterior surface

Answer 36

Pleural friction rub