Chapter 19 - Physical Assessment

Question 1

What is the primary goal of a physical assessment?

Answer 1

To identify the patient’s problem and plan appropriate interventions

Question 2

What is the initial step of the nursing process and the first step in forming the nursing care plan?

Answer 2

Assessment / Recognizing Cues

Question 3

The nurse is gathering information from a patient who came into the ED after a fall at home. You are gathering their health history - which is what stage of the nursing care plan?

Answer 3

Assessment

Question 4

What makes up the integumentary system?

Answer 4

Hair, nails, skin

Question 5

Comprehensive assessment of physical, mental, spiritual, socioeconomic and cultural status is?

Answer 5

Health Assessment

Question 6

A focus on a client’s functional ability and physical responses to illness is?

Answer 6

Nursing Assessment

Question 7

Techniques used in health or nursing assessment to gather objective data is?

Answer 7

Physical Assessment

Question 8

This includes the nursing assessment and physical exam while obtaining subjective data about each area?

Answer 8

Physical Examination

Question 9

What are the 4 purposes of the physical exam?

Answer 9

1. Obtain baseline data
2. Identify a nursing diagnosis
3. Monitor status of previous problems
4. Screen for health problems

Question 10

A system specific assessment focuses on?

Answer 10

One body system

Question 11

A comprehensive exam includes?

Answer 11

Health history interview and head to toe exam

Question 12

As assessment that is performed in intervals or as needed is referred to as what?

Answer 12

Ongoing assessment

Question 13

What techniques are used in a physical exam?

Answer 13

Inspection, palpation, percussion, auscultation and olfaction

Question 14

What is fowler position?

Answer 14

Head elevated to 60 degrees

Question 15

What is semi-fowler position?

Answer 15

Head elevated to 30-45 degrees

Question 16

When would you perform a comprehensive exam?

Answer 16

When a patient is admitted

Question 17

When is a rapid assessment performed?

Answer 17

Each shift (after the admission when a comprehensive exam was performed)

Question 18

Using sight to gather data is what type of assessment technique?

Answer 18

Inspection

Question 19

Using touch to assess body organs and skin uses which assessment technique?

Answer 19

Palpation

Question 20

Tapping the skin to cause a vibration is what type of assessment technique?

Answer 20

Percussion (usually performed by MD or ARNP)

Question 21

Listening to sounds made by body organs or systems uses which assessment technique?

Answer 21

Auscultation

Question 22

Listening without tools such as a stethoscope is referred to as?

Answer 22

Direct auscultation

Question 23

Listening with a stethoscope is referred to as?

Answer 23

Indirect auscultation

Question 24

What does pallor look like in a light skinned client and a dark skinned patient?

Answer 24

Light skinned patient has extreme paleness, dark skinned patient has a loss of red tones

Question 25

Pallor can be related to which two things?

Answer 25

Poor circulation or low hemoglobin level (aka anemia)

Question 26

Where are the best sites to assess for pallor?

Answer 26

oral mucous membranes, conjunctiva, nail beds, palms, soles of feet

Question 27

Asking a patient what year it is assesses if they are oriented to what?

Answer 27

time

Question 28

Asking a patient where they are assesses if they are oriented to what?

Answer 28

place

Question 29

Asking a patient their name assesses if they are oriented to what?

Answer 29

self

Question 30

Asking the patient why they are in the hospital assesses if they are oriented to what?

Answer 30

Event

Question 31

Alert and oriented x4 (A&O x4) means the patient is oriented to what four things?

Answer 31

self, time, place, event

Question 32

Checking for alert and oriented it part of what assessment?

Answer 32

Neuro

Question 33

What does PERRLA stand for?

Answer 33

Pupils Equal Round Reactive to Light Accommodation

Question 34

How do you know if the eyes accommodate?

Answer 34

The pupils restrict and the eyes cross as a person attempts to focus on an object moving towards them

Question 35

What is the normal size of a pupil in bright light?

Answer 35

2-3mm

Question 36

What is ptosis?

Answer 36

A drooping eye lid

Question 37

What does wheezing sound like?

Answer 37

A whisteling sound

Question 38

What do rales sound like?

Answer 38

crackling sound

Question 39

What does rhonchi sound like?

Answer 39

course, wet sound

Question 40

What do you note if sputum is present?

Answer 40

Color and amount

Question 41

While auscultating lung sounds, which pattern should be used?

Answer 41

zig-zag

Question 42

A thyroid glad should be … (3 things)

Answer 42

smooth, firm, non-tender