CH 30/31 Physical Assessment

Question 1

What is AIDET?

Answer 1

Acknowledge
Introduce
Duration
Explanation
Thank you

Question 2

What is the proper order of methods you will use to assess? (not abdominal)

Answer 2

Inspection
Palpation
Percussion
Auscultation

Question 3

What part of the hand is most sensitive to textures and shape?

Answer 3

The finger pads and palm of the hand

Question 4

What part of the hand is best for assessing temperature?

Answer 4

the dorsal surface (back) of the hand

Question 5

Jaundice

Answer 5

Yellow staining of body tissues and fluids

Question 6

Erythema

Answer 6

Skin redness caused by inflammation

Question 7

Cyanotic

Answer 7

Blue grey or dark purple skin discoloration

Question 8

What is lack of skin turgor an indicator of?

Answer 8

dehydration

Question 9

What is pitting edema?

Answer 9

When pressed firmly with a finger, tissues that are swollen with extravascular fluid retain the shape of the depression produced by the finger.

Question 10

What are the different ratings for severity of pitting edema?

Answer 10

1+
2+
3+
4+

Question 11

What is ABCDE for skin lesions/ moles?

Answer 11

Asymmetry
Border Irregularity
Color
Diameter
Elevation

Question 12

What can clubbing of nails indicate?

Answer 12

respiratory problems

Question 13

Nystagmus

Answer 13

Involuntary back-and-forth or cyclical movements of the eyes

Question 14

Arcus senilis

Answer 14

An opaque white ring about the periphery of the cornea, seen in the aged. It is caused by the deposit of fat granules in the cornea or by hyaline degeneration.

Question 15

Ptosis

Answer 15

Drooping of the eyelid over the pupil area - edema or cranial nerve IIV impairment, in the elderly can be a result of loss of elasticity

Question 16

Ectropion / entropion lid margins

Answer 16

The eyelid may be turned inward or outward

Question 17

What is PERRLA?

Answer 17

Pupils 
Equal
Round
React to 
Light
Accomodate

Question 18

How do you test for accommodation?

Answer 18

Have the patient look at something close - about 12 inches away
Close-converge-constrict
Now have them look at something distant
Distant-diverge-dilate

Question 19

cerumen

Answer 19

ear wax

Question 20

Weber Test

Answer 20

Hears sound equally in both ears - tuning fork at top of head

to persons with unilateral conductive-type deafness, the sound will be perceived as being more pronounced on the diseased side; in persons with unilateral nerve-type deafness, the sound will be perceived as being louder in the good ear.

Question 21

Rinne Test

Answer 21

The vibrating fork is held by its stem on the mastoid process of the ear until the patient no longer hears it. Then it is held close to the external auditory meatus. If the subject still hears the vibrations, air conduction exceeds bone conduction (this is the normal finding).

Question 22

Which sinuses should you palpate?

Answer 22

frontal and maxillary

Question 23

Should you palpate both carotid arteries at the same time?

Answer 23

No!

Question 24

Tactile fremitus

Answer 24

sound created by the vocal chords that’s then transmitted through the lungs to the chest wall

Question 25

crackles

Answer 25

fine medium or course - disruption in air passage through small airways

Question 26

rhonchi

Answer 26

lower pitched and continuous sounds caused by muscular spasm or mucous in the larger airways

Question 27

wheezes

Answer 27

high pitched continuous musical sounds during inspiration our inspiration (asthma)

Question 28

pleural friction rub

Answer 28

dry rubbing or grating quality - inflamed pleura rubbing against eachother

Question 29

What should you list when documenting abnormal lung sounds?

Answer 29

Location and abnormal quality of the sound

Question 30

adventitious breath sounds

Answer 30

abnormal sounds

Question 31

Where is the point of maximal impulse for the heart?

Answer 31

Between the 4th and 5th intercostal next to the mid clavicular line

Question 32

dysrhythmia

Answer 32

Failure of the heart to beat at regular successive intervals

Question 33

Murmurs

Answer 33

sustained swishing or blowing sounds heard at the beginning, middle or end of the systolic or diastolic phase. graded 1-6

Question 34

``` Aortic Pulmonic Erbs Tricuspid Mitral ```

Answer 34

Aortic valve area: 2nd ICS just right of sternum Pulmonic: 2nd ICS just left of sternum Erb’s point: 3rd ICS just left of sternum Tricuspid: 4th ICS just left of sternum Mitral: 5th ICS midclavicular line

Question 35

What is it called when you hear a whoosh whoosh sound listening to a carotid artery?

Answer 35

a bruit

Question 36

Jugular vein distention (JVD)

Answer 36

bulging of the jugular veins - most visible on the right side

Question 37

How do you rate pulse?

Answer 37

``` 0- no pulse 1- very weak pulse 2- Normal pulse 3- full pulse 4- bounding ```

Question 38

In what order of assessment methods will we assess the abdomen?

Answer 38

Inspection Auscultation Palpation percussion

Question 39

What are different ways we can describe bowl sounds?

Answer 39

``` normal audible absent hyperactive hypoactive ```

Question 40

How often should a patient preform a breast self exam? What is the best time to do so?

Answer 40

Once a month - 2-3 days after the end of a period

Question 41

Loridosis

Answer 41

lower back - inward curvature

Question 42

kyphosis

Answer 42

upper back - outward curvature

Question 43

scoliosis

Answer 43

S shaped curve or twist of spine

Question 44

hypotonia

Answer 44

decreased muscle tone

Question 45

hypertonicity

Answer 45

Muscle overactivity

Question 46

atrophy

Answer 46

wasting or loss of muscle tissue

Question 47

A&O x 4?

Answer 47

Name and DOB? Where are you? What is the day/ time? Why are you here?

Question 48

Glasgow coma scale measures 3 things...

Answer 48

eyes motor verbal

Question 49

CN I - XII

Answer 49

I- Olfactory -- smell -- sensory II- Optic -- sight -- sensory III- Oculomotor -- eye movement -- motor IV- Trochlear -- eye movement -- motor V- Trigeminal -- face sensation/ chewing -- both VI- Abducens -- eye movement -- motor VII- Facial -- facial movement / taste -- both VIII- Vestibulocochlear -- balance/ hearing -- sensory IX- Glossopharyngeal -- taste/swallowing -- both X- Vagus -- taste/swallow/parasympathetic--both XI- Spinal Accessory -- head/shoulder -- motor XII- Hypoglossal -- tongue -- motor

Question 50

Deep tendon reflex ratings

Answer 50

``` 0 - no response +1 - sluggish response +2 active expected +3 brisk response +4 hyperactive response ```