Chapter 20 key terms questions

Question 1

What is the major difference between a general assessment and specific or focused assessment as far as how you would begin?

Answer 1

Part of the general assessment, the nurse will observe the patients appearance and behavior than go into vitals. Specific or focused assessments are done after the general assessment where a detailed health history will be done.

Question 2

2. Name what each position is best for: Supine

Answer 2

easy to assess critical anatomy like your neck, chest, abdomen, pulses

Question 3

Name what each position is best for: Fowler

Answer 3

comfortable for those short of breath, there is also high fowler.

Question 4

What are the four assessment techniques and examples:

Answer 4

Inspection, palpitation, percussion, and auscultation

Question 5

Inspection

Answer 5

viewing the patient, hands off. Look at their overall affect, hygiene, appearance

Question 6

Palpitation-

Answer 6

• palpating the pulses (brachial, radial, popliteal, dorsal pedis, plantar) listening for crepitus or looking at any signs of pain (palpating the abdomen, sinuses).

Question 7

Percussion

Answer 7

taping the body to locate or approximate the size, shape, location of organs, masses, and fluids.

Question 8

Auscultation

Answer 8

listening. When we listen to breath, bowel, pulses, heart

Question 9

A nurse notes that a patient has patches of white skin around their eyes and mouth and parts of their arms due to lack of melanin. This patient likely has what?

Answer 9

Albinism

Question 10

A Nurse notes a blue discoloration around the nose and eyes of an infant, this is likely caused by what?

Answer 10

Cyanosis

Question 11

A nurse is assessing a patient with end stage liver failure. The nurse will likely notate what characteristic of the patient’s skin?

Answer 11

Jaundice, yellowing

Question 12

Which part of the stethoscope is used for bowel sounds?

Answer 12

The diaphragm

Question 13

A nurse can be most efficient in educating about melanoma and tanning beds if she targets which group?

Answer 13

Teen-35. Research indicates that indoor tanning before the age of 35 increase the chance of melanoma by 59%. P. 336

Question 14

The nurse is assessing male genitalia. What are some assessment factors she will focus on?

Answer 14

Look for lumps, bumps, lesions, scabbing, infestation. If the male is uncircumcised, gently pull back the foreskin to inspect (clean if necessary) and ensure it placed back over the head of the penis to avoid infection or loss of use.

Question 15

When assessing the abdomen, the nurse knows that she must complete it in a different order which is?

Answer 15

Inspect, auscultate, palpate. Remember that the abdomen is divided into four quadrants and the large intestine ascends from right lower into the right upper where it transverses across to the left upper and descends to the left lower quadrant.

Question 16

A nurse is assessing a patient who was just in a serious accident with head trauma. The nurse notes that the patient is exhibiting inability to balance when standing and difficulty breathing and coordinating his breaths. The nurse notes he likely damaged which lobes of his brain?

Answer 16

Cerebellum and Brainstem

Question 17

The nurse is assessing a patients’ lower extremity. What are the five P’s she will be looking for?

Answer 17

Pain, Pallor, Pulselessness, Paresthesia, Paralysis

Question 18

What is normal capillary refill? What should the nurse assess if it is longer?

Answer 18

Normal is 2-3 seconds, longer usually a sign of cardiovascular disease or hypoxia

Question 19

The nurse is conducting an Allens test on a patient, what is this?

Answer 19

It shows the circulation of the hands, the nurse will press on the hand and the blanch should return within 10 seconds

Question 20

There are six types of Cardiac murmurs, what are they?

Answer 20

Grade 1 scarcely audible with a good stethoscope in a quiet room
Grade 2 quiet but readily audible with a stethoscope
Grade 3 Easily heard with a stethoscope
Grade 4 Loud obvious murmur with palpable thrill
Grade 5 Very Loud with palpable thrill heard over the pericardium and elsewhere in the body
Grade 6 Heard with a stethoscope off the chest, thrill is palpable and visible.

Question 21

The nurse notes that the patients radial pulse is slower than the apical pulse and knows that this is called what?

Answer 21

pulse deficit

Question 22

What are signs of an abdominal aortic aneurism?

Answer 22

Abdominal bruits or pulsations, these are assessed by placing the bell of the stethoscope over the abdominal aorta.

Question 23

The nurse is auscultating a patients heart and hears the expect S1 and S2, however, she notices a sound just before the S1, what is her course of action and why?

Answer 23

This is an S4 heart murmur and is a pulse deficit. It needs to be reported to the primary care provider for further investigation

Question 24

The nurse hears the following sounds: Crackles, Rhonchi, Wheezing, Stridor, and Pleural Friction Rub. What do they indicate?

Answer 24

Crackles-alveoli in the lungs are collapsed by fluid or exudate, heard with COPD, Pulmonary Edema, left sided heart failure.
Rhonchi- Heard with PneumoniaWheezing- airways are severely obstructed or constricted due to asthma, foreign objects, bronchiectasis, or emphysema.
Stridor- indicative of serious airway obstruction from epiglottitis, croup, foreign body lodged in the airway or laryngeal tumor.
Pleural Friction Rub- inflamed pleural surfaces rubbing together, due to pneumonia or pleuritis

Question 25

When assessing the lungs where are the positions of the stethoscope placed? What part of the stethoscope?

Answer 25

8 places on the front starting at the sternum and going side to side not up and down so you can compare. 10 on the back same way and two on the sides (armpit and lower rib)
You are using the diaphragm of the stethoscope

Question 26

. The nurse is assessing a patient with cerebral palsy. She knows that this assessment will result in what abnormal finding in relation to breathing. What other morbidities can cause this?

Answer 26

The impairment causes a decreased movement of the thoracic cage, this can cause decreased oxygenation or greater susceptibility for infection due to pooled secretions or trapped air. Other diagnosis that causes this are rib fracture, or severe skeletal muscle deformities like kyphosis.

Question 27

A nurse is assessing a patient with COPD; she notes that the patient findings will likely include what common symptom?

Answer 27

A barrel chest appearance. The patient will loose strength in their neck with forced respirations causing them to adopt a tripod position (leaning forward with the arms braced against the knees, chair, or bed).

Question 28

How does the nurse examine the carotid arteries?

Answer 28

Use the bell of the stethoscope and palpate one at a time. You should here a “whooshing” sound. DO NOT PALPATE AT THE SAME TIME

Question 29

. The nurse assesses a patient’s neck and finds that it is distended and large where the thyroid should be. What is this finding consistent with?

Answer 29

Hyper/Hypo thyroids, Goiter. Needs to be looked at by an MD or Advanced Practice Nurse.

Question 30

The nurse is assessing a patient using the Rinne test. The nurse knows that should the patient have conductive hearing loss, what results will show? What about sensorineural loss?

Answer 30

Patients with conductive hearing loss will hear bone conduction sounds longer than air or as long as air sounds. Patients with sensorineural hearing loss air is heard longer only slightly than bone conduction.

Question 31

The nurse is checking the eyes of a three-year-old patient. Which vision chart would work best?

Answer 31

The E chart

Question 32

During assessment, the nurse notes that patient requires assistance to achieve full ROM, the muscles feel loose and flaccid. What would the description be of this?

Answer 32

Hypotonicity with passive ROM

Question 33

Nurse is assessing a patient with knee pain who complains of abdominal discomfort. Which position would the nurse place him for assessment?

Answer 33

The supine position is good for both complaints

Question 34

What position is ideal for facilitating insertion of vaginal speculum and inspection of the female genitalia?

Answer 34

Lithotomy position