General Survey and Physical Assessment

Question 1

A comprehensive health assessment always begins with a general survey. What are the observational components to a general survey?

Answer 1

observation of clients general apprearance, mental status,

measurement of vital signs, height, weight, and waist circumference.

Question 2

In a general survey, what is looked at when inspecting the head?

Answer 2

hair and face
eyes and vision
ears and hearing 
nose
mouth and oropharynx

Question 3

In a general survey, what is looked at when inspecting the neck?

Answer 3

muscles
lymph nodes
trachea 
thyroid gland
carotid arteries
neck veins

Question 4

In a general survey, what is looked at when inspecting the upper extremities?

Answer 4

skin and nails
muscle strength and tone 
joint range of motion 
brachial and radial pulses
sensation

Question 5

In a general survey, what is looked at when inspecting the chest and back?

Answer 5

skin
thorax shape and size
lungs 
heart
spinal column 
breast and axillae

Question 6

In a general survey, what is looked at when inspecting the abdomen?

Answer 6

skin
abdominal sounds
femoral pulses

Question 7

In a general survey, what is looked at when inspecting the external genitals?

Answer 7

only external genitals

Question 8

In a general survey, what is looked at when inspecting the anus?

Answer 8

only anus

Question 9

In a general survey, what is looked at when inspecting the lower extremities?

Answer 9

skin and toenails
gait and balance
joint range of motion
popliteal, posterior tibial, and dorsalis pedis pulses

Question 10

For a physical health examination, how can a nurse prepare the client?

Answer 10

by introducing self and explaining procedure, reason of exam, and what client can exprect

Question 11

For a physical health examination, how can a nurse prepare the environment?

Answer 11

by obtaining all necessary equipment, including adequate lighting and drapes for privacy, and adjusting room temp

Question 12

What is inspection?

Answer 12

visual examination

Question 13

what is palpation?

Answer 13

examining body using touch

Question 14

What is palpation used to determine?

Answer 14

texture
temperature
vibration
position, size, consistency, and mobility of organ masses
distention 
presence and rate of peripheral pulses 
tenderness or pain

Question 15

What are the 2 types of palpation?

Answer 15

light and

deep-two handed (bimanually) or one handed

Question 16

What is percussion?

Answer 16

body surface is struck to elicit sounds that can be head or vibration that can be felt.

Question 17

What are the 2 types of percussion?

Answer 17

direct and indirect

Question 18

Flatness

Answer 18

an extremely dull sound head when percussing over very dense tissue

Question 19

Dullness

Answer 19

a thudlike sound heard with percussion over dense tissue

Question 20

Resonance

Answer 20

hollow sound (lung filled with air)

Question 21

Hyperresonance

Answer 21

booming

Question 22

Tympany

Answer 22

musical or drumlike sound produced when percussing an air-filled organ (eg.stomach)

Question 23

What is auscultation?

Answer 23

the process of listening to sounds produced within the body

Question 24

What is pitch?

Answer 24

the frequency of the vibrations (number of vibrations/sec)

Question 25

What is intensity?

Answer 25

(AMPLITUDE) refers to the loudness or softness of a sound

Question 26

What is duration?

Answer 26

sounds length

Question 27

What are the different vital signs?

Answer 27

measurements of temperature, pulse, respirations, blood pressure, and oxygen saturation.

Question 28

1kg=___lbs.

Answer 28

2.2

Question 29

How do you perform direct percussion?

Answer 29

nurse strikes area to be percussed directly with pads of 2,3 or 4 fingers or with the middle finger. -strikes are rappid

Question 30

How do you perform indirect percussion?

Answer 30

Striking of an object (eg.finger) held against the body area,

Question 31

How do you perform light palpation?

Answer 31

nurse extends the fingers of the dominant hand parallel to the skin surface and presses gently while moving hand in a circle. -skin is slightly depressed

Question 32

How do you perform deep palpation?

Answer 32

top hand applies pressure while lower hand remains relaxed to perceive the tactile sensation

Question 33

When assessing appearance and mental status, what are you observing?

Answer 33

1. Observe body build, height, weight in relation to age, lifestyle and health 2. Observe posture and gait, standing sitting and walking, 3. Observe overall hygiene and grooming 4. note body and breathe odor 5. Observe signs of distress in posture or facial expressions. 6. note obvious signs of health or illness 7. Assess clients attitude (frame of mind) 8. note clients affect/mood; assess appropriateness of responses. 9. Listen to quality of speech and quantity 10. Listen for relevance and organization of thoughts.

Question 34

What does the integumentary system consist of?

Answer 34

hair, nails, and skin

Question 35

What is vitiligo?

Answer 35

patches of hypopigmented skin

Question 36

What is albinism?>

Answer 36

complete or partial lack of melanin in the skin, hair, and eyes

Question 37

What is edema?

Answer 37

excess interstitial fluid - makes skin appear swollen, shiny, and taut, - tends to blanch color

Question 38

What is a skin lesion?

Answer 38

an alteration in a clients normal skin appearance

Question 39

What is the difference between primary skin lesions and secondary skin lesions?

Answer 39

primary-response to a change in the external or internal environment of the skin secondary- result from modifications such as chronicity, trauma, or infection of a primary skin lesion

Question 40

What is pallor?

Answer 40

paleness - absence of underlying red tones in skin and may be most readily seen in the buccal mucosa - results from inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation.

Question 41

What is cyanosis?

Answer 41

Blueish tinge - most evident in the nail beds, lips, and buccal mucosa. - in dark skinned clients, close inspection of the palpebral conjunctiva (linning of eyelid), palms, and soles.

Question 42

What is jaundice?

Answer 42

Yellow tinge - in sclera of the eyes and then in the mucous membrane and skin, - if suspected, check posterior part of hard palate for yellowing

Question 43

What is Erythema?

Answer 43

redness associated with a variety off skin disorders

Question 44

What is a translucent, dry, paper-like, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin?

Answer 44

Atrophy | examples: striae, aged skin

Question 45

What is is called when the superficial epidermis is wearing away causing a moist, shallow, depression?

Answer 45

Erosion | eg. scratch marks, ruptured vesicle

Question 46

How come erosions dont scar?

Answer 46

because they do not extend into the dermis

Question 47

What is it called when an area of the epidermis is rough, thickened, and hardened resulting from chronic irritation such as scratching or rubbing?

Answer 47

Lichenification | eg. chronic dermititis

Question 48

What is it called when flakes of greasy, karatinized skin tissue sheds?

Answer 48

Scales | eg. dry skin, dandruff, psoriasis and eczema

Question 49

What is the color and texture of scales?

Answer 49

color-white, gray, or silver | texture-varies from fine to thick