Chapter 31: Health Assessment and Physical Examination

Question 1

Physical exam is conducted to: (5)

Answer 1

Gather baseline data about the patient’s health status

Supplement, confirm, or refute subjective data obtained in nursing history

Identify and confirm nursing diagnoses

Make clinical decisions about a patient’s changing health status and management

Evaluate the outcomes of care

Question 2

Palpate skin for

Answer 2

temperature

moisture

texture

turgor

tenderness

thickness

abdomen- tenderness, distention, masses

Question 3

Palmar surface of the hand and finger pads are more

Answer 3

sensitive than fingertips and should be used to determine

position

texture

size

consistency

masses

fluid

crepitus

Question 4

Assess body temperature by using

Answer 4

dorsal surface, back of hand

Question 5

Percussion involves:

Answer 5

tapping the skin with the fingertips to vibrate underlying tissues and organs

Question 6

If you suspect that alcohol abuse is a major problem, use the CAGE questionnaire

Answer 6

C: have you ever felt the need to CUT DOWN on your drinking or drug use?

A: Have people ANNOYED you by criticizing your drinking or drug use?

G: Have you felt bad or GUILTY about your drinking or drug use?

E: Have you ever used or had a drink first thing in the morning as an EYE OPENER to steady your nerves or feel normal?

Question 7

Bluish (cyanosis)

Answer 7

Increased amount of deoxygenated hemoglobin (associated with hypoxia)

Heart or lung disease, cold environment

Nail beds, lips, mouth, skin (severe cases)

Question 8

Pallor (decrease in color)

Answer 8

Reduced amount of oxyhemoglobin

Anemia
Shock

Face, nail beds, palms of hands, skin

Question 9

Loss of pigmentation

Answer 9

Vitiligo

Congenital or autoimmune condition causing lack of pigment

Patchy areas on skin over face, hands, arms

Question 10

Yellow-orange (jaundice)

Answer 10

increased deposit of billirubin (brownish, yellow substance found in tissue