Unit 1&2

Question 1

When do nurses perform a physical assessment?

Answer 1

• Patient admission
• Patient transfer-start of shift
• patient discharge

Question 2

When commenting on somebodies general appearance or mental status what two things should you use?

Answer 2

descriptive language and appropriate comments

Question 3

What is a normal body temperature?

Answer 3

36 C (96.8 F) to 38 C (100.4)

Question 4

afebril

Answer 4

normal body temperature

Question 5

febrile

Answer 5

increased body temperatue

Question 6

pyrexia

Answer 6

fever or body temperature above normal

Question 7

hyperpyrexia

Answer 7

high fiver, usually above 41 C (105.8 F), also referred to as hyperthermia

Question 8

hypothermia

Answer 8

body temperature below the lower limit of normal

Question 9

Rate

Answer 9

frequency

Question 10

rhythm

Answer 10

pattern of pulsations. can be regular or irregular

Question 11

amplitude

Answer 11

quality (thready, weak, normal, bounding)

Question 12

Eupnea

Answer 12

normal breathing (12 20 breaths/minute)

Question 13

tachypnea

Answer 13

greater than 24 breaths per minute

Question 14

bradypnea

Answer 14

less then 10 breaths per minute

Question 15

dyspnea

Answer 15

difficult or labored breathing

Question 16

orthopnea

Answer 16

breathes more easily in an upright position

Question 17

apnea

Answer 17

temporary cessation of breathing

Question 18

stridor

Answer 18

high pitch harsh sound usually on expiration (croup)

Question 19

grunting

Answer 19

forced expiration

Question 20

hyperventilation

Answer 20

Kussmul’s (diabetic ketoacidosis)

Question 21

hypoventilation

Answer 21

anesthesia or narcotics

Question 22

cheyne stokes

Answer 22

deep and apnea, reg. (dying)

Question 23

biot’s

Answer 23

varying depth and apnea, irreg. (meningitis)

Question 24

What does Blood pressure refer to?

Answer 24

refers to the force of the blood against the arterial wall.

Question 25

normal blood pressure

Answer 25

<80 (diastolic)

Question 26

hypertension

Answer 26

above normal for a sustained period of time

Question 27

hypotension

Answer 27

below normal blood pressure

Question 28

orthostatic hypotension

Answer 28

low blood pressure associated with weakness or fainting when rising to and erect position.

Question 29

Phase 1 of Korokoff's sounds

Answer 29

a sharp tapping between 140-130

Question 30

Phase 2 of Korokoff's sounds

Answer 30

a swishing or whooshing sound 130-120

Question 31

Phase 3 of Korokoff's sounds

Answer 31

a thump softer than the tapping in phase 1

Question 32

phase 4 of Korokoff's sounds

Answer 32

a softer blowing muffled sound that fades

Question 33

Phase 5 of Korokoff's sounds

Answer 33

silence

Question 34

what are the factors of oxygen saturation?

Answer 34

Hemoglobin, circulation, CO poisoning.

Question 35

when look at the skin what things do you look for?

Answer 35

documentation, lesions (ABCD), other abnormalities, nails

Question 36

When looking at the head and neck what do you look at?

Answer 36

hair. scalp, contour, ROM, fontanels

Question 37

When looking at the eyes what do you look for?

Answer 37

symmetry, color, movement, pupils, PERRLA

Question 38

When looking at the head what do you look for

Answer 38

size, shape, position, lesions, piercing, hearing

Question 39

when looking at the nose and sinuses what do you look for?

Answer 39

position, symmetry, patency

Question 40

When looking at the mouth and oropharynx what do you look for

Answer 40

symmetry, color, moisture, teeth, strength

Question 41

When looking at the thorax and lungs what do you look for,

Answer 41

color, symmetry, PMI palpate and ausculate

Question 42

what is Ausculation?

Answer 42

when you listen with a stethescope

Question 43

When looking at the cardiovascular what do you look for?

Answer 43

landmarks, apical pulse, peripheral color, temperature, sensation, edema, pulses (describe)

Question 44

what does APe To Man mean

Answer 44

Aoritic, Pulmonic, Tricuspid, mitral

Question 45

when hearing the lub dub sound in the heart what causes the lub?

Answer 45

the tricuspid and mitral valves closing, also called S1

Question 46

When hearing the lub dub sound in the heart what causes the dub?

Answer 46

the aortic and pulmonic valves close, S2

Question 47

When looking at the breast and axillae what do you look for?

Answer 47

symmetry, irregularities, self exam

Question 48

When looking at the abdomen what do you look for?

Answer 48

observe: skin, distension, peristalsis ausculate for active, absent hypo- or hyper active bowel, bruits palpate

Question 49

What places should you listen to when ausculating the abdomen?

Answer 49

aorta, renal artery, illiac artery, femoral artery