Ch.13 Physical Assesment

Question 1

A(n) ____________ is an instrument used to examine structures in the eye.

Answer 1

Ophthalmoscope

Question 2

A(n) ____________ is a professional trained to test hearing with standardized instruments.

Answer 2

Audiologist

Question 3

____________ is an exaggerated natural lumbar curve of the spine.

Answer 3

Lordosis

Question 4

____________ is excessive fluid within tissue and signifies abnormal fluid distribution.

Answer 4

Edema

Question 5

The yellowish brown, waxy secretion produced by glands within the ear is called ____________.

Answer 5

Cerumen

Question 6

A(n) ____________ chart is a visual assessment tool with small print.

Answer 6

Jaeger

Question 7

The ____________ test is an assessment technique for comparing air versus bone conduction of sound.

Answer 7

Rinne

Question 8

____________ is a combination of the elastic quality of the skin and the pressure exerted on it by fluid within.

Answer 8

Turgor

Question 9

A(n) ____________ test is an assessment technique for determining equality or disparity of bone-conducted sound.

Answer 9

Weber

Question 10

Identify and label the figure.

Answer 10

Question 11

How is a taste assessment done?

Answer 11

Assessment of taste is facilitated by placing substances on the tongue and asking clients to identify them with their eyes closed.

Question 12

How does the nurse ensure valid results when assessing taste in a client?

Answer 12

To ensure valid results, the nurse instructs the client to sip water between assessments.

Question 13

Identify the figure.

Answer 13

The figure shows assessment of the muscle strength of the lower extremities.

Question 14

How would the nurse test the strength in a client’s upper extremities?

Answer 14

The nurse assesses all four extremities separately to determine muscle strength.

To test strength in the lower extremities, the nurse has the client push and pull against resistance.

To assess strength in the upper extremities, the nurse asks the client to grasp, squeeze, and release their fingers. As the nurse pulls and pushes on the forearm and upper arm, they instruct the client to resist.

Question 15

Ability to see both far and near.

Answer 15

Visual acuity

Question 16

Ability to read printed letters at a distance of 20 feet without prescription lenses.

Answer 16

Normal vision

Question 17

Brisk, equal, and simultaneous constriction of both pupils when one eye, and then the other eye, is stimulated with light

Answer 17

Consensual response

Question 18

Assessment of peripheral vision and continuity in the visual field.

Answer 18

Visual field examination

Question 19

Ability to constrict when looking at a near object and dilate when looking at an object in the distance

Answer 19

Accommodation of pupils

Question 20

Presented here, in random order, are steps occurring during the assessment of pupillary response. Write the correct sequence in the boxes provided.

1. Repeat the assessment by directly stimulating the opposite eye
2. Ask the client to look at a finger or object approximately 4 inches from their face
3. Bring a narrow beam of light from a penlight, from the temple toward the eye
4. Tell the client to look from the near object to another that is more distant
5. Dim the lights in the examination area and instruct the client to stare straight ahead
6. Observe the pupil of the stimulated eye as well as the unstimulated pupil

Answer 20

5. Dim the lights in the examination area and instruct the client to stare straight ahead
6. Bring a narrow beam of light from a penlight, from the temple toward the eye
7. Observe the pupil of the stimulated eye as well as the unstimulated pupil
8. Repeat the assessment by directly stimulating the opposite eye
9. Ask the client to look at a finger or object approximately 4 inches from their face
10. Tell the client to look from the near object to another that is more distant

Question 21

What is the purpose of a physical assessment?

Answer 21

A physical assessment is done for the following reasons:

To evaluate the client’s current physical condition

To detect early signs of developing health problems

To establish a baseline for future comparisons

To evaluate the client’s responses to medical and nursing interventions

Question 22

What are the basic requirements of an examination room for assessing clients?

Answer 22

Clients are examined in a special examination room or at the bedside.

The examination area should have easy access to a

Restroom

A door or curtain that ensures privacy

Adequate warmth for client comfort

A padded, adjustable table or bed

Sufficient room for moving to either side of the client

Adequate lighting

Facilities for hand hygiene

A clean counter or surface for placing examination equipment

A lined receptacle for soiled articles.

Question 23

Why is it important to document the client’s weight and height during an initial assessment?

Answer 23

It is important for the nurse to document the client’s weight and height because they provide more reliable data than a subjective assessment of body size. The recorded measurements help to assess trends in future weight loss or gain. Dosages of certain drugs are calculated on the basis of the client’s weight and height.

Question 24

How should the nurse assess a client’s hair?

Answer 24

The nurse assesses the scalp hair, eyebrows, and eyelashes during assessment of a client’s hair. The nurse notes the color, texture, and presence or absence of hair in unusual locations for sex or age. They also inspect the hair for debris, such as blood in a client with head trauma; nits; or scales from scalp lesions. As the physical assessment progresses, the nurse also observes characteristics of body hair.

Question 25

Why is it important for the nurse to document any unusual characteristics of the nails or surrounding tissues?

Answer 25

It is important for the nurse to document any unusual characteristics of the nails or surrounding tissues because changes in the shape and thickness of the fingernails and toenails are often signs of chronic cardiopulmonary disease or fungal infections.

Question 26

What equipment would the nurse need for a basic physical assessment?

Answer 26

For a basic physical assessment, a nurse requires gloves, examination gown, cloth or paper drapes, scale, stethoscope, sphygmomanometer, thermometer, penlight or flashlight, tongue blade, assessment form, and a pen.

Question 27

*The first step in the nursing process is assessment. The overall goal of physical assessment is to gather objective data about a client. Answer the following questions, which involve the nurse’s role in the physical assessment of clients.

A nurse is caring for a client with an abdomen that appears unusually enlarged. The nurse is assessing the bowel as part of the physical assessment.

1. In what order should the nurse use the assessment techniques?

Answer 27

The abdomen is always inspected and then auscultated before using palpation or percussion techniques. Touching or manipulating the abdomen can alter bowel sounds, producing invalid findings.

Question 28

How should the nurse measure the abdominal girth of the client?

Answer 28

The nurse checks the abdominal girth daily by using a tape measure around the largest diameter. To ensure that they always measure from the same location, the nurse makes guide marks on the skin with an indelible pen.

Question 29

A nurse is caring for a middle-aged client at the health care facility. During the physical assessment, the nurse asks the client to perform a regular testicular self-examination. The client is not aware of the method of self-examination.

What should the nurse tell the client with regard to the procedure for testicular self-examination?

Answer 29

The nurse should ask the client to examine the testes monthly during bathing or showering and to adhere to the following procedure:

Elevate the penis with one hand.

Gently roll each testicle within the scrotum between the thumb and the index finger.

Feel each testicle horizontally.

Feel each testicle vertically.

Check for any unusual lumps.

Continue palpation following the spermatic cord from the testicle to where it ascends into the abdomen.

Report any unusual findings to a physician as soon as possible.