Week #2: Physical Assessment Flashcards
(163 cards)
1
Q
In a comprehensive assessment, which data about the patient will most likely be collected? 4x
A
- Present level of wellness
- Changes in life patterns
- Sociocultural roles
- Mental and emotional reactions to illness
2
Q
What assessment is used as a general health assessment?
A
Nursing physical assessment
3
Q
Gathering biographical information from a patient is a component of what assessment?
A
Comprehensive
4
Q
Which assessment incudes a review of diagnostic data? (Lab or radiologic)
A
Comprehensive
5
Q
Checking for the patients physical health patterns, food and drug allergies and medication history are all components of what assessment?
A
Comprehensive
6
Q
When obtaining an holistic evaluation, this is most likely what kind of assessment?
A
Nursing physical assessment
7
Q
The _______ ______ assessment is used to gather data about the patient.
A
Nursing physical
8
Q
The nursing physical assessment focuses on functional abilities and responses to ________ and _______.
A
Illnesses and stressors
9
Q
Name the four types of physical examinations.
A
- Comprehensive
- Focused
- System-specific
- Ongoing
10
Q
Which type of physical examination is performed on admission?
A
Comprehensive
11
Q
This type of physical examination is limited to one body system.
A
System-specific
12
Q
Which of the following type of assessment would a nurse perform on a a patient who is having problems breathing due to COPD?
A. Comprehensive health assessment
B. Focused-assessment
C. Initial head-to-toe
D. None of the above
A
B
13
Q
What are the two types of data?
A
- Objective
- Subjective
14
Q
Observation of measurements of a patients health status is which type of data?
A
Objective data
15
Q
The patients verbal descriptions of their health problems.
A
Subjective data
16
Q
The size or condition of a patients wound or the description of an observed behavior, vital signs are all examples of which form of data?
A
Objective
17
Q
A patient rates his level of back pain, expresses his feelings and perceptions. Based off of the information, what type of data is this considered?
A
Subjective
18
Q
When preparing the environment, what are the five things to consider?
A
- Privacy
- Noise
- Enable visualization
- Temperature
- Equipment
19
Q
What are the four steps to promise client comfort?
A
- Develop report
- Explain the procedure
- Respect cultural differences
- Proper positioning
20
Q
What are 6 major skills used within a physical assessment?
A
- Interview
- Inspection
- Palpating
- Percussion
- Auscultation
- Olfaction
21
Q
Interview techniques include observation and four types of questions, what are they?
A
- Direct Closed-ended
- Open-ended
- Leading
- Probing
22
Q
Watching facial expressions and body language is an interview technique of?
A
Observation
23
Q
_________ questions guide the patient to a specific topic.
A
Leading
24
Q
________ questions let you dig deeper on a topic you are on.
A
Probing
25
When interviewing a patient about a fall, a ________ question would be, “Did you hit your head?” If yes, _______ questions would follow up with would be, “Did you lose consciousness at all? Are you bleeding? Do you have a headache?”
Leading
Probing
26
Physical assessment technique questions: _________ is the use of sight to gather data.
Inspection
27
Inspection is used throughout the _________ _______.
Physical examination
28
What are the three tools used to enhance inspection?
1. Otoscope
2. Ophthalmoscope
3. Penlight
29
Use of touch to gather data
Palpation
30
An example of examining the patients skin color, gait, general appearance and behaviors are all examples of which physical assessment technique?
Inspection
31
Physical assessment technique questions: ________ begins with light pressure, moving to deep palpation.
Palpation
32
Physical assessment technique questions: when performing palpitations, the fingertips are used to perform?
Tactile discrimination
33
Physical assessment technique questions:
When you’re palpating to obtain a temperature determination, which part of your hand is being utilized?
Dorsum
34
Physical assessment technique questions: when palpating for a general area of pulsation, which part of your hand is being used?
Palm
35
Physical assessment technique questions: when grasping a patient, you are using both, your fingers and your thumb for a ______ _______.
Mass evaluation
36
Tapping on skin to elicit sound.
Percussion
37
Physical assessment technique questions: there are two different ways to perform percussion, what are they?
Direct and indirect
38
This physical assessment technique is useful for assessing abdomen, lungs, underlying structures. An example would be a distended bladder.
Percussion
39
When practicing percussion, you’re listening to the sounds. Dull sounds indicate a ______ structure below and hallow sounds which indicates ______ ______ spaces are below.
Solid
Air filled
40
Physical assessment technique questions: Use of hearing to gather assessment data is what?
Auscultation
41
There are two types of auscultation, what are they?
1. Direct
2. Indirect
42
Physical assessment technique questions: In regards to auscultation, listening without an instrument is called ______ auscultation, and use of a stethoscope to listen is called ______ auscultation.
Direct
Indirect
43
Physical assessment technique questions: when utilizing a stethoscope, which part of the stethoscope has a high pitch sound? And which part of the stethoscope has low-pitched sounds?
Diaphragm and Bell
44
The nurse would be able to gather the most complete data about the clients pedal edema using the assessment skill of:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
2. Palpation
Although inspection would alert the nurse to the presence of edema, palpation will determine the degree to which it has occurred.
45
When performing a physical examination on a toddler, perform the ______ _______ last.
Invasive procedure
46
ADL’s
Activity of daily living
47
Ankle swelling is a symptom of which heart condition?
Congestive heart failure
48
The general survey begins at first _______.
Contact
49
Speech based: Inappropriate or illogical responses may be associated with _______ _______.
Psychiatric Disorders
50
Speech based: Difficulty speaking or changes in voice quality may indicate a ________ problem.
Neurological
51
Speech based: rapid speech may be a sign of ______ or use of _______.
Anxiety
Stimulants
52
Speech based: hoarseness of the voice could indicate _________ of the throat.
Inflammation
53
Speech based: slow speech may be due to what three things?
1. Depression
2. Sedation
3. Neurological disorders
54
Speech based: a foreign accent with hesitancy and or sparse verbalization may signal a _______ _______ and may need an interpreter.
Language barrier
55
Mental state indicates what two things?
LOC
Confusion
56
Dressing/grooming/hygiene tells us about ability to care for themselves is considered an impression of a client undergoing a _______ survey.
General
57
Age modifications for PA: show approval and develop rapport
School-age children
58
Age modifications for PA: provide privacy
Adolescents
59
Age modifications for PA: allow independence
School age children
60
Age modifications for PA: address concerns that they are normal
Adolescents
61
Age modifications for PA: allow child to help with examination
Preschoolers
62
Age modifications for PA: allow to explore and/or sit on parents lap, offer choices and use praise
Toddlers
63
SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the first S stand for?
Sleep disorders
64
SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the P stand for?
Problems with eating or feeding
65
SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the I stand for?
Incontinence
66
SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the C stand for?
Confusion
67
SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the E stand for?
Evidence of falls
68
SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the S stand for?
Skin breakdown
69
Pain will increase 4 vital signs, what are they?
1. BP
2. PULSE
3. TEMPERATURE
4. RESPIRATIONS
70
A client hospitalized with renal calculi (kidney stones) complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the clients vital signs, which include:
1. Decreases pulse rate
2. Increased blood pressure
3. Decreased respiratory rate
4. Decreased temperature
2
71
A nurse is routinely monitoring a patients BP. What should the nurse do first when the assessment reveals a change in the patients blood pressure?
A. Report the change to the charge nurse
B. Document the observed change
C. Notify the health-care provider
D. Obtain the other vital signs (HR, Temp, etc.)
D
72
When assessing a patients vital signs, the nurse understands that an essential principal of vital signs assessment is (select all that apply:
1. Comparing the vital signs to the normal ranges for the patients age.
2. Comparing a patients baseline of prior viral signs to the current reading.
3. Asking the patient if he or she remembers the last set of vital signs.
4. There is no need to compare current vital signs to previous vital signs
1,2,3
73
A female patient, age 48, comes to the clinic with complaints of dizziness and a frontal headache. She tells you she is under a lot of stress because her husband was recently laid off. She is 5’4 and weighs 150 lb. You take her blood pressure and it is 178/100. When you tell her the blood pressure reading, she says, “This cannot be right! I usually run 100/60.” What should be your next action?
1. Tell the patient that stress can raise BP so that must be it.
2. Wait 2 minutes and retake the blood pressure in the other arm.
3. Call in the health-care provider to retake the BP.
4. Document the blood pressure as high.
2
74
When you obtain a BP measurement on a patient that resulted in a high measurement, wait for about _____ minutes and retake the blood pressure in the opposite arm; document the _______ of the two blood pressure readings.
2
Higher
75
The purpose of inspecting and palpating the head is to assess for normal ______ and ______ of the head.
Shape and size
76
When inspecting a patients head, what is the equipment that needs to be used?
Gloves
77
When performing an inspection and Palpation for a patients head, you must inspect the patients head for what four things?
1. Shape
2. Size
3. Configuration
4. Movement
78
When performing Palpation for a patients head, you must palpate it for what three things?
Tenderness
Masses or depressions
79
A disorder associated with excess growth hormone, will cause a patient to have a large head. Occurs in adolescence or adult patients.
Acromegaly
80
An abnormally small head size in infants, is caused by a variety of genetic and environmental factors. What is this called?
Microcephaly
81
________ may be the result of trauma, surgery, neuromuscular disorder, paralysis, or congenital deformity.
Asymmetry
82
In infants and children, a head that is growing disproportionately faster than the body may be a sign of ___________.
Hydrocephalus
83
An accumulation of excessive cerebrospinal fluid.
Hydrocephalus
84
All children between the ages of ________ months and ______ years old are considered children.
24 months
11
85
An adolescent age ranges from ______ years to ______ or ______.
12
16 or 18
86
Hair changes can be related to what 4 things?
1. Diet
2. Stress
3. Infection
4. Endocrine disorders
87
What three things do you look at when performing an inspection on the general condition of hair?
1. Amount
2. Distribution
3. Cleanliness
88
What two things are you observing when performing a general condition of the scalp?
1. Hair color
2. Hair texture
89
Hair loss along the temples and in the center of the scalp is considered a normal balding pattern in men and is largely genetically based.
Alopecia
90
________ alopecia can be caused by chemotherapy for the treatment of cancer, by nutritional deficiencies, or by endocrine disorders.
Diffuse
91
Patchy hair loss may be caused by a fungal infection of the scalp, hair pulling, constant wearing of caps. A benign autoimmune disorder.
Alopecia Areata
92
Pediculosis
Head lice
93
When assessing for visual acuity, what equipment is being used?
Snellen chart
94
When assessing for visual acuity, the patient stands ______ ft away from the Snellen chart.
20
95
When assessing for visual acuity, have the patient cover the ______ eye and start reading from the top to the bottom, out loud.
Left
96
When performing for visual acuity, ask about what two things?
Glasses or contacts
97
Normal distant visual acuity is _______/_______.
20/20
98
Assessing visual acuity: The higher the _________ means poorer distant visual acuity.
Denominator
99
Nearsightedness
Myopia
100
Diminished distant vision
Myopia
101
What is the score resulting in legal blindness?
20/200
102
What equipment do you use to assess for color blindness?
Ishihara plate
103
Yellow ________ ________ may be seen with an elevated bilirubin.
Icteric Sclera
104
PERRLA
1. Pupils
2. Equal
3. Round
4. Reactive to…..
5. Light
6. Accommodation
105
________ is a growth or thickening of conjunctiva from the inner canthus toward the iris.
Pterygium
106
An everted eyelid, is commonly seen in older adults secondary to loss of skin tone. It can lead to excessive dryness of the eyes.
Ectropion
107
Inverted eyelid, can lead to corneal damage.
Entropion
108
Drooping of the lid, may be seen in clients who have experienced a stroke or Bell’s palsy.
Ptosis
109
CVA (stroke)
Cerebrovascular accident
110
Ptosis, or drooping of the lid, may be seen in clients who have experienced a ________ or _____ ______.
Stroke
Bell’s palsy
111
Paralysis of the facial
Nerve
Bell’s Palsy
112
When inspecting pupil size and consensual response, you must stand in front of the patient, and use the penlight to inspect the pupils for what three things?
1. Color
2. Shape
3. Symmetry
113
When performing an inspection of pupil size and consensual response, you are to measure the size of each pupil in ________.
Millimeters
114
Inspecting _____ _______ and _______ response is to assess the pupillary light reflex that controls the diameter of the pupil, and to assess the integrity of the optic pathways (consensual response).
Pupil Size
Consensual
115
Patient focuses on a far object and then focuses on near objects, in response, the patients pupils should get smaller for focusing on close objects.
This is an example of testing for ________.
Accommodation
116
Testing for ______ _______, is to assess for weakness or problems with the ocular muscles.
Ocular motility
117
When performing a test for ocular motility, use a finger or an object in your hand about _____to_______ inches from the patients face.
12 to 14
118
When performing a test for ocular motility, move the object in six different positions using a wide ____ or a _____ pattern.
H or star
119
Normal ear size ranges from _____ cm to ____ cm.
4-10
120
Skin turgors refers to ________ of the skin.
Turgor
121
Ringing or a buzzing sound in the ears
Tinnitus
122
________ is the perception of sound when no actual external noise is present; it is commonly referred to as “ringing in the ears!”
Tinnitus
123
When inspecting the ears, what two tests are performed?
1. Weber and Rinne tests
2. Romberg test
124
When performing an inspection on a patient ear, start assessing them during the first encounter, noting whether “_________ _______” is intact.
Conversational hearing
125
A ______ implant bypass damaged portions of the ear and directly stimulates the auditory nerve.
Cochlear
126
Inspecting and palpating the nose, purpose is to check for ______, _______ or ______.
Tenderness, deviation or inflammation
127
Nasal drainage
Rhinitis
128
Nose bleed
Epistaxis
129
When inspecting the mouth, what tools are used?
Penlight
130
Dry mouth with decreased saliva. Many medications can cause dry mouth.
Xerostomia
131
Enlargement of the thyroid gland.
Goiter
132
When inspecting the neck, the neck should be slightly ________.
Hyperextended
133
JVD
Jugular vein distension
134
Skin turgor under <3 sec is considered _________.
dehydration
135
Loss of ability to understand or express spoken or written language.
Aphasia
136
Person has difficulty coordinating and organizing words into sentences.
Dysphasia
137
What are the three forms of Dysphasia:
1. Receptive
2. Expressive
3. Global
138
Dysphasia: difficulty in comprehension
Receptive
139
Dysphasia: deficits in comprehension, naming, and speech production
Global
140
Dysphasia: difficulty in putting words together to make meaning
Expressive
141
Able to open eyes but is drowsy and falls asleep readily.
Lethargy
142
Client responds to light shaking but can be confused and slow to respond.
Obtunded
143
Client requires painful stimuli (sternal rub or pinch) to achieve a brief response.
Stuporous
144
No response to repeated painful stimulus
Comatose
145
MMSE
Mini Mental State Examination
146
AVPU
Level of arousal/stimuli response
147
BMR
Basal metabolic rate
148
The MMSE is used to test for complaints of problems with _______ or other _______ _______.
Memory
Mental abilities
149
What three things can you look at when obtaining a patients circulation?
1. Pulse
2. Temperature
3. Capillary refill
150
When obtaining a patients sensation levels, you must touch their ______/_________ to see if they can feel it
Fingers and toes
151
What are the three major signs of a stroke?
1. Face droops
2. Arm weakness
3. Speech difficulty
152
Name two types of spinal deformity.
Scoliosis and Kyphosis
153
Crackling skin caused by the air in the SQ tissue
Crepitus
154
A Barrel chest is a result from ______.
COPD
155
Funnel chest is more common in _______ (gender)
Male
156
______ chest is a protrusion of the sternum with a backward sloping of the ribs.
Pigeon
157
Is difficulty or inability to breathe when lying down. Pt’s with respiratory or cardiac problems
Orthopnea
158
Hemoptysis
Blood in phlegm.
159
Inspiration should be _____ times longer than expiratory phase.
3x
160
Shortness of breath with activity
Exertional Dyspnea
161
High pitched musical sounds, usually with increased expiration. Wheezes.
Asthma
162
Course crackles
Rhonchi
163
Fluid in the alveoli causes a ______ sounds.
Crackling
