Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Physical Assessment > Unit Two Test > Flashcards

Unit Two Test Flashcards

(104 cards)

Start Studying
1
Q

sources of data in Interview

A

primary and secondary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

primary is

A

patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

secondary is

A

from family or chart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what are the phases of the interview

A

orientation
working
termination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

begins at the introduction, knock on door and introduce self

A

orientation phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

collecting data, actually doing your physical care and planning nursing care

A

working phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

documented and saved data at end of assessment with patient

A

termination phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

physical examination is when you

A

gather by observation, look, listen, and feel

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

what are the types of physical assessment

A

comprehensive

focused and systemic specific

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

ongoing and head to toe are not assessments that are separate, they are part of the

A

comprehensive, focused and system specific

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

in depth assessment where you are manipulating the body to get a medical diagnosis from it (PA or NP usually do this)

A

comprehensive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

obtain specific info based on pt admitting dx or potential problem (ex. shortness of breath- assess lungs and respiration, oxygenation, color of skin)

A

focused

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

focusing on only one system (we will do every system assessment)

A

system specific

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

how often do you have to come into the room is

A

ongoing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

all assessments we do this in a systematic way to help us not leave anything out)

A

head to toe

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what is the nursing process of physical assessment

A

assessment
nursing diagnosis
planning
evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

what are the 5 techniques for assessment

A 
inspection
palpation
percussion
auscultation
olfaction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

observing is

A

inspection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

touching is

A

palpation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

listening by THUMPING is

A

percussion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

listen with stethoscope is

A

auscultation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

smelling is

A

olfaction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

in assessment we use all senses except

A

taste!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

when inspecting what should you do with body parts not being inspected

A

drape or cover body parts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
what parts are needing additional lighting
eyes, ears, throat
26
what are you observing for
color, shape/symmetry, movement, position
27
what is considered light palpation
1cm or 1/2 in depth
28
what is considered deep palpation
4cm or 2in depth
29
what are the techniques of palpation
bimanual/ manual dorsum of hand palm or ulnar surface of hand plamar surface of finger/finger pads
30
you palpate to assess
texture, resistance, resilience, mobility, temperature, thickness, shape and moisture
31
what is another word used for moist
diaphoric
32
where should you assess turgor
at clavicle
33
what are the 2 ways to percuss
direct and indirect
34
applied directly to body is
direct
35
applied through another or surface is
indirect
36
where do you typically percuss
over the stomach and the intestines
37
what are the characteristics of auscultation
frequency loudness quality duration
38
of oscillations per second generated by a vibrating object
frequency
39
amplitude of a sound wave
loudness
40
descriptive is
quality
41
length of time that sound lasts is
duration
42
when using the stethoscope it is always best to
directly place it on skin
43
best for LOW pitched sounds
bell
44
best for HIGH pitch sounds
diaphragm
45
olfaction is used to detect
abnormal and normal symptoms
46
what should you clean between clients
stethoscope head and blood pressure cuffs
47
what are the special considerations when assessing for the aged
may need to adjust position may need to allow more time may need to allow more space
48
when is the health history taken
before physical exam
49
what is the exception for taking height and weight
only need to take it upon admitted and not usually taken continuously unless patient has fluid filling
50
when measuring circumference what is measured
head, chest, stomach, legs
51
when should vital signs be taken
evry 4 hours unless noted otherwise
52
what do lasix (diuretic) meds do to a patient
tend to make patient urinate more and expect weight to drop
53
when a pt has swollen legs what should be done
elevation and TED hose
54
blue skin=
not enough oxygenation
55
yellow skin=
jaundice
56
turgor is checked for
hydration status
57
bright red bleeding of a wound should be
reported
58
in integument what are you assessing
oxygenation, circulation, nutrition, tissue damage, hydration (skin nails and hair)
59
if pt has been on bedrest pay extra attention to
skin over bony prominences such as elbows, coccyx, hips and heels
60
if there is redness on skin what should you do
check for blanching
61
fluid building (pooling in certain areas(
pitting edema
62
how would you document pitting edema status
press until you feel bone and depending on how far deep finger goes is what you document
63
terminal hair is
scalp, axillae, pubic, and beard
64
vellus hair is
soft tiny hairs covering the body except palms and soles
65
hair loss
alopecia
66
excessive hair
hirsutism
67
when the nail has long term oxygen deprivation (finger enlarges because it hasn't been the normal growth
clubbing
68
a pupil dilated in
the dark
69
a pupil constricts in the
light
70
when is the only time pupils will not react
if pt has cataracts, trauma, injury to head
71
what is the pupillary reflex
``` Pupils Equal Round Reactive Light (Accommodation) PERRLA ```
72
abscess teeth can cause
heart disease
73
clear liquid in ears is
cerebrospinal fluid (indicated head injury)
74
low set ears=
downsyndrome
75
red ears=
fever, ear infection, picking at ear
76
extreme palor=
paleness (not getting enough oxygen, or cold)
77
jugular vein distention usually indicates
high blood pressure
78
COPD people cannot
recoil and have difficulty breathing (their level of carbon dioxide makes them take a breath)
79
funnel chest=
indention (nothing wrong unless doing CPR)
80
pigeon chest
structure of sternum the way it grows outward
81
check for scoliosis by
bending over and touching toes
82
kyphosis
hunchback
83
type of breathing pattern where pt is going through a hard time of breathing (panting)
kussmauls
84
why should you ask pt for history of smoking
history can cause lung damage and affect what we are hearing
85
when assessing cardiovascular what is the PMI (point of maximum impulse)
5th intercostal space just medially to the left mid clavicular line)
86
when should you listen to apical
if radius is abnormal or pt is taking digoxin (for qt intervals)
87
sound associated with closing of mitral/tricuspid valves
lub or S1
88
sound associated with the closing of the aortic/pulmonic valves
Dub or S2
89
``` pulse points 0 1+ 2+ 3+ 4+ ```
``` 0= absent non palpable 1+= diminished, palpable 2+= strong, normal 3+= full, inceased 4+= bounding ```
90
typically around feet and ankles; older adults and those who stand a lot
dependent edema
91
venous insufficiency or R heart failure, fluid accumulates in tissue
pitting edema
92
when assessing gastrointestinal what should you ask the patient to do
go to the bathroom before assessment
93
in gastrointestinal assessment no deep palpation more interested in
the bowel sounds
94
why do you palpate the abdomen last
palpation causes unneeded sounds
95
what hinders abdomen exam
tense muscles
96
what order should the assessment go
inspection, auscultation, percussion, palpation
97
bowel sounds normal=
5-35 times per minute
98
bowel sounds of hyperactive=
greater than 35 times per minute
99
bowel sounds of hypoactive=
less than 5 times per minute
100
bowel sounds of absense=
5 minutes
101
areas of air are
stomach
102
areas of solid masses
liver, intestines
103
when should you use light palpation (1/2 in depth)
using palm of hand with fingers extended check - distended bladder - superficial masses - tenderness
104
IV sites are NOT considered a wound it is a
access site

Physical Assessment (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions