Unit 2: Chapter 30 Health Assessment Flashcards
(21 cards)
Ms. Taylor arrives at the clinic for a routine health exam. She reports no specific complaints but mentions increased fatigue and a recent unintentional weight loss.
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Which of the following is the correct sequence for the abdominal assessment?
A. Inspection → Palpation → Percussion → Auscultation
B. Palpation → Auscultation → Inspection → Percussion
C. Inspection → Auscultation → Percussion → Palpation
D. Auscultation → Inspection → Palpation → Percussion
C
Abdominal assessment requires auscultation before palpation or percussion to avoid altering bowel sounds.
Match the types of physical assessment techniques with their primary function:
Technique Function
Inspection ☐ Visual observation for symmetry, color, size
Palpation ☐ Assess texture, temperature, tenderness
Percussion ☐ Determine tissue density and organ borders
Auscultation ☐ Listen to internal body sounds
Inspection = visual, Palpation = touch, Percussion = density, Auscultation = internal sounds
Which of the following findings during a general survey should be reported for further evaluation? (Select all that apply)
A. Gait imbalance
B. Body odor
C. Clear speech
D. Well-groomed appearance
E. Visible distress
A, B, E
Gait imbalance, odor, and distress are signs needing evaluation.
Match the age group with the recommended approach to assessment:
Age Group Approach
Children ☐ Gain trust before examining
Adolescents ☐ Ensure confidentiality
Adults ☐ Focus on health risks and preventive care
Older Adults ☐ Allow more time and observe for fatigue
Children = trust, Adolescents = confidentiality, Adults = prevention, Older = time/fatigue
To inspect the thyroid gland, the nurse should ask the patient to:
[ Select ]
Options:
Swallow
Tilt their head back
Inhale deeply
Puff out their cheeks
Swallow
Helps visualize thyroid movement or enlargement.
During auscultation of the lungs, which sound is normal over the periphery of the lung fields?
A. Bronchial
B. Bronchovesicular
C. Vesicular
D. Crackles
C
Vesicular sounds are soft and heard over peripheral lung fields.
Place the steps of a cardiac assessment in the correct order of auscultation locations (head-to-toe):
☐ Aortic area
☐ Pulmonic area
☐ Tricuspid area
☐ Mitral area
Aortic → Pulmonic → Tricuspid → Mitral
Match each reflex grade with its clinical interpretation:
Reflex Grade Interpretation
0 ☐ No response
2+ ☐ Normal response
3+ ☐ Brisk, possibly normal
4+ ☐ Hyperactive with clonus
0 = no response, 2+ = normal, 3+ = brisk, 4+ = hyperactive
The trigeminal nerve (CN V) is assessed by testing:
[ Select ]
Options:
Facial symmetry and expression
Tongue movement and strength
Light touch and jaw movement
Eye movement in six directions
Light touch and jaw movement – Sensory and motor function of CN V
What is the primary purpose of the Mini-Mental State Examination (MMSE)?
A. Evaluate joint mobility
B. Assess cognitive function
C. Detect respiratory insufficiency
D. Identify pain threshold
B
MMSE assesses memory, orientation, and attention
The normal angle between the nail plate and the nail bed is approximately ______ degrees.
160
Normal nail bed angle.
Which steps are part of preparing the examination environment? (Select all that apply)
A. Dim the lights
B. Ensure privacy
C. Warm stethoscope before use
D. Leave the door open
E. Provide a comfortable temperature
B, C, E
Provide comfort and privacy.
Match each breast examination technique with its correct application:
Technique Description
Inspection ☐ Observe size, symmetry, skin, and nipples
Palpation ☐ Use vertical, circular, or radial pattern
Lymph node palpation ☐ Examine axillary and clavicular areas
Inspection = visual, Palpation = systematic pattern, Lymph = axilla/clavicle
During male genital assessment, which finding is normal?
A. Tender nodules in scrotum
B. Foreskin cannot retract
C. Glans smooth with slit-like meatus
D. Redness and swelling of urethral opening
C
Smooth glans and slit-like meatus are normal.
To assess cranial nerve II, the nurse should:
[ Select ]
Options:
Test gag reflex
Evaluate hearing
Test visual acuity
Assess facial sensation
Test visual acuity
CN II = optic nerve
Match the abnormal spinal curvatures with their definition:
Curvature Definition
Kyphosis ☐ Hunchback curvature
Lordosis ☐ Swayback curve of lower spine
Scoliosis ☐ Lateral spine deviation
Kyphosis = hunchback, Lordosis = swayback, Scoliosis = lateral curve
Which observations during a skin assessment require further investigation? (Select all that apply)
A. Cyanosis of the lips
B. Moist, pink oral mucosa
C. Clubbing of the fingers
D. Capillary refill <2 seconds
E. Jaundice of sclera
A, C, E
Cyanosis, clubbing, and jaundice may indicate systemic issues.
Match each eye assessment component with its normal finding:
Component Normal Finding
Pupils ☐ Round, equal, reactive to light
Conjunctiva ☐ Pink and moist
Sclera ☐ White or light yellow
Extraocular movement ☐ Parallel tracking in all directions
Pupils = equal, reactive, Conjunctiva = pink, Sclera = white/yellow, EOM = parallel
Which patient factors may influence the interpretation of physical exam findings? (Select all that apply)
A. Cultural health beliefs
B. Medication use
C. Ambient room temperature
D. Body position
E. Nurse’s attire
A, B, C, D
All except nurse’s attire affect findings.
During auscultation, S1 corresponds with the closure of the ________ and ________ valves.
Mitral and tricuspid – S1 marks beginning of systole.
