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Med Surge > Physical Assesment > Flashcards

Physical Assesment Flashcards

1
Q

The nurse is collecting data during an initial assessment. The data that can be seen, heard, measured, or felt and is objective is called a(n):

A

sign. (A sign can be seen, heard, measured, or felt.)

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2
Q

As part of an assessment, the nurse asks the patient for subjective information related to the present illness. Subjective findings that are perceived by the patient are known as:

A

symptoms.- are subjective indications of illness that are perceived by the patient.

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3
Q

Any disturbance of a structure or function of the body is a pathological condition. This condition is termed a(n):

A

disease.- is any disturbance of a structure or function of the body.

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4
Q

The nurse is assessing a patient to collect subjective and objective data. These data will provide the basis for making a:

A

nursing diagnosis.

-Nurses rely on assessment of signs and symptoms to formulate a nursing diagnosis.

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5
Q

The nurse is discussing the origin of diabetes with a diabetic patient. The most appropriate explanation is that this disease is caused by a dysfunction of the

A

pancreas.-Diabetes mellitus results from dysfunction of the pancreas.

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6
Q

There are four categories of factors that increase an individual’s vulnerability to developing a disease: genetic, physiological, age, and lifestyle. These are called:

A

risk factors

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7
Q

When discussing diabetes with a patient, the nurse describes this disease as falling into which group in terms of duration?

A

Chronic-Diabetes mellitus is an example of a chronic disease.

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8
Q

The term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease is:

A

remission.

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9
Q

When a disease results in a structural change in an organ that interferes with its functioning, this is a(n):

A

organic disease.

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10
Q

Although the signs and symptoms of both infection and inflammation include erythema, edema, and pain, the major difference is that inflammation:

A

Inflammation is a protective response.

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11
Q

A nursing assessment is a process of collecting data to establish a database. The information contained in the database is the basis for:

A

an individualized plan of care.-

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12
Q

The nurse is meeting a patient for the first time. The initial step when initiating a nurse-patient relationship is for the nurse to:

A

introduce her/himself.-

The first step in a nurse-patient relationship is for the nurse to introduce her/himself.

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13
Q

A patient interview being conducted by the nurse should convey to the patient that the nurse has:

A

feelings of concern.

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14
Q

While conducting an assessment of a patient, the nurse recognizes that the initial step is:

A

the nursing health history.

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15
Q

When collecting data related to the present illness, the nurse must obtain detailed and comprehensive data to assist in establishing:

A

appropriate interventions.
The data collected related to the present illness must be detailed and comprehensive to allow planning of appropriate interventions.

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16
Q

During the nursing interview, several histories are taken. The history that involves data concerning habits and lifestyle patterns is called:

A

past health history

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17
Q

The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. This method is a

A

A review of systems is a systematic method.

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18
Q

The nurse is developing a nursing care plan for a newly admitted patient. The first step in developing this care plan is a:

A

health history.-

The nursing assessment is the critical step in forming the nursing care plan.

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19
Q

The patient should be assessed as soon as possible after admission. This initial assessment is done by the:

A

RN.-The initial assessment is done by the registered nurse.

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20
Q

A patient was admitted with a complaint of abdominal pain. Later, the nurse observed the patient demonstrating dyspnea. This change in condition requires an assessment called

A

focused.-When the nurse observes a change in the patient’s condition, the assessment is focused.

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21
Q

When performing a nursing physical assessment, the nurse uses a head-to-toe approach. When using this method, the nurse begins with a:

A

neurological assessment.

-When performing a head-to-toe assessment, the nurse begins with a neurological assessment.

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22
Q

An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. The nurse recognizes this could be caused by:

A

dehydration

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23
Q

During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse and are most often heard:

A

during inspiration-

Crackles are usually heard during inspiration.

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24
Q

Auscultating the heart sounds should result in a “lubb-dupp” sound when using the bell and the diaphragm of the stethoscope. The “lubb” sound is caused by the:

A

closing of the AV valves

The “lubb-dupp” sound of the heart is caused by the closing of the AV and semilunar valves, respectively.

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25
Q

The nurse assesses a patient for capillary refill. After the fingernail is compressed for 5 seconds, the refill time should be fewer than:

A

3 seconds

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26
Q

Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. The normal rate of bowel sounds per minute is:

A

4-32.

The normal rate of bowel sounds per minute is 4-32.

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27
Q

A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 2+ pitting edema because the edema disappears in:

A

10-15 seconds.

The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds.

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28
Q

Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. Percussion is used to determine:

A

density of underlying tissue.

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29
Q

The nurse is obtaining a history of a patient’s present illness. The PQRST system is used for the interview. In this system, the R stands for:

A

region.

In the PQRST system, the R stands for region.

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30
Q

When performing a physical examination of a patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. This technique is:

A

deep palpation

Deep palpation is used to detect tenderness or masses of the abdomen.

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31
Q

The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. These are identified as:

A

sonorous wheezes.
Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.

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32
Q

When auscultating the thorax, the suggested sequence for a systematic approach is to begin with the:

A

apices. The suggested sequence for a systematic auscultation of the thorax is to begin with the apices.

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33
Q

A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective? The patient:

A

appears to be anxious. Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Anxiety is the only objective assessment finding. All other options are examples of subjective data.

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34
Q

A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data?

A

The patient expectorates red-tinged sputum. Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Expectoration of red-tinged sputum is the only objective assessment finding. All other options are examples of subjective data.

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35
Q

A nurse is gathering subjective data when admitting a patient. Which assessment finding is considered subjective data? The patient:

A

complains of chest pain. Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Chest pain is the only subjective assessment finding. All other options are examples of objective data.

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36
Q

A nurse is gathering subjective data when admitting a patient. Which assessment finding is considered subjective data? The patient:

A

complains of pruritus. Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Pruritis is the only subjective assessment finding. All other options are examples of objective data.

37
Q

A nurse is gathering subjective data when admitting a patient. Which assessment finding is considered subjective data? The patient:

A

complains of diplopia. Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Diplopia is the only subjective assessment finding. All other options are examples of objective data.

38
Q

When performing a head-to-toe assessment, the nurse should begin by assessing the patient’s:

A

neurological status. When performing a head-to-toe assessment, the nurse begins with a neurological assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.

39
Q

During a head-to-toe assessment, the nurse assesses the patient’s abdomen. Which area should the nurse assess next?

A

Perineal area. When performing a head-to-toe assessment, the nurse begins with a neurological assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.

40
Q

During a head-to-toe assessment, the nurse assesses the patient’s perineal area. Which area should the nurse assess next?

A

Legs and feet. When performing a head-to-toe assessment, the nurse begins with a neurological assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.

41
Q

During a neurological assessment, the nurse notes a patient has a unilateral, dilated, and nonreactive pupil. This is a sign that the patient is experiencing pressure on which cranial nerve?

A

III- The third cranial nerve runs parallel to the brain stem. The function of the oculomotor nerve is essential for eye movements. A traumatic brain injury can result in increased intracranial pressure, edema to the brain stem with pressure on cranial nerve III, causing the ominous sign of a unilateral, dilated, and nonreactive pupil.

42
Q

A physician needs to insert a vaginal speculum into a patient for a vaginal examination. The nurse should place the patient in what position?

A

Lithotomy

Lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum.

43
Q

A physician needs to assess extension of a patient’s hip joint. The nurse should place the patient in what position?

A

Prone

Prone position is used to assess extension of a patient’s hip joint.

44
Q

A physician needs to assess a patient for a heart murmur. The nurse should place the patient in what position?

A

Lateral recumbent

Lateral recumbent position aids in detecting heart murmurs.

45
Q

A physician needs to assess a patient’s rectal area. The nurse should place the patient in what position?

A

Knee-chest- position provides maximum exposure of the rectal area.

46
Q

A nurse needs to auscultate a patient’s lung sounds. The nurse should place the patient in what position?

A

Sitting– upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts

47
Q

During a physical assessment, the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. The nurse should document that the patient is experiencing:

A

Cyanosis-
is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.

48
Q

During a physical assessment, the nurse notes a patient has a lack of appetite resulting in an inability to eat. The nurse should document that the patient is experiencing:

A

anorexia.-

is a lack of appetite resulting in the inability to eat. This symptom can occur in many disease conditions.

49
Q

During a physical assessment, the nurse notes a patient has a loss of strength and energy. The nurse should document that the patient is experiencing:

A

asthenia.-

is a condition of debility, loss of strength and energy, and depleted vitality

50
Q

During a physical assessment, the nurse notes that a patient’s heart rate is 56 beats per minute. The nurse should document that the patient is experiencing:

A

Bradycardia-
is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute.

51
Q

During a physical assessment, the patient complains of difficulty in passing stools. The nurse should document that the patient is experiencing:

A

Constipation-
is difficulty in passing stools or an incomplete or infrequent passage of hard stools. There are many causes, both organic and functional.

52
Q

During a physical assessment, the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. The nurse should document that the patient is experiencing:

A

.Coughing
-is a sudden audible expulsion of air from the lungs. Coughing is an essential protective response that serves to clear the lungs, bronchi, or trachea of irritants and secretions or to prevent aspiration of foreign material into the lungs. It is a common sign of diseases of the larynx, bronchi, and lungs.

53
Q

During a physical assessment, the nurse notes a patient has profuse secretions of sweat. The nurse should document that the patient is experiencing:

A

Diaphoresis
-is the secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress.

54
Q

During a physical assessment, the nurse notes a patient passes frequent loose liquid stools. The nurse should document that the patient is experiencing:

A

Diarrhea
-is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools can mean there is bleeding in the intestines. Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.

55
Q

During a physical assessment, the nurse notes that a patient has bright red blood in the feces. The nurse recognizes that the bleeding is most likely caused by:

A

bleeding in the lower intestinal tract

Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.

56
Q

A nurse is caring for a patient with congestive heart failure. During the physical assessment, the nurse notes the patient is experiencing difficulty breathing. The nurse should document that the patient is experiencing

A

Dyspnea-
is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety.

57
Q

A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. The nurse should document that the patient has:

A

Ecchymosis

58
Q

When admitting a patient to the hospital, the nurse notes the patient has mild sunburn. The nurse should document this finding as:

A

Erythema- is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries; erythema is seen in mild sunburn.

59
Q

When assessing a patient with hepatitis, the nurse notes a yellow tingle to the patient’s skin. The nurse understands that jaundice most likely results from an obstruction in the flow of bile from the:

A

liver.-

Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

60
Q

When assessing a patient, the nurse notes a yellow tinge to the patient’s skin. The nurse should document that the patient has:

A

Jaundice

is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

61
Q

When assessing a patient, the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient to a sitting position, the patient is able to breathe more easily. The nurse should document that the patient is experiencing:

A

Orthopnea-
is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems.

62
Q

When assessing a patient, the nurse notes that the patient has an unnatural paleness of color to the skin. The nurse should document this finding as:

A

skin pallor.
Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes.

63
Q

When assessing a patient, the patient complains of an uncomfortable sensation leading to an urge to scratch. The nurse notes the patient scratching frequently. The nurse should document that the patient is experiencing:

A

Pruritus
- is a symptom of itching and an uncomfortable sensation leading to an urge to scratch. Some causes are allergy, infection, jaundice, elevated serum urea, and skin irritation.

64
Q

A physician documents that a patient is having purulent drainage from a wound. The nurse understands that this is most likely caused by:

A

bacterial infection
-Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance.

65
Q

A physician documents that a patient has a sallow complexion. The nurse understands that this means the patient has a:

A

-yellow color to the skin.

Sallow is an unhealthy, yellow color; usually said of a complexion or skin.

66
Q

A physician documents that a patient has a scleral icterus. The nurse understands this indicates that the color of the patient’s sclera is:

A

yellow.

-Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body.

67
Q

A physician documents that a patient has a scleral icterus. The nurse understands this indicates that the color of the patient’s sclera is yellow and is caused by infiltration of:

A

bilirubin.

-Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body.

68
Q

When assessing a female for risk factors associated with coronary artery disease, what information should the nurse include? (Select all that apply.)

A

a. Family history of illness
b. Diet
c. Smoking
d. Exercise
all options would be informative about risk for heart disease.

69
Q

Which are infectious diseases? (Select all that apply.)

A

a. Measles
b. Pneumonia
c. Tuberculosis
d. Acquired immunodeficiency syndrome

Infectious diseases result from the invasion of microorganisms into the body. Examples of infectious diseases include acquired immunodeficiency syndrome (AIDS), tuberculosis, measles, and pneumonia. Hay fever is a manifestation of an allergic reaction, and osteoarthritis is an example of a degenerative disease.

70
Q

The nurse notes that a patient has difficulty breathing in the supine position, and the patient admits that he sleeps in a recliner at home. These are cardinal signs of ____________ disease.

A

COPD

Long-term pulmonary disease makes it difficult for the patient to breathe without distress in the supine position. They frequently sleep in a recliner chair.

71
Q

When auscultating the chest, a nurse hears crackles in both lower lobes. To further assess this finding, the nurse should ask the patient to

A

cough

It is a useful assessment to determine that the patient can clear the secretions by coughing.

72
Q

The nurse observes an older adult patient has no hair on the lower legs. The nurse should assess further for the sufficiency of _________ ________.

A

arterial flow

-Reduced arterial flow causes lack of hair on the lower extremities due to inadequate blood flow.

73
Q

Arrange these assessment techniques in correct order of a standard physical examination.

A
  1. Inspection
  2. Palpation
  3. Auscultation
  4. Percussion
    The usual sequence of assessment= is inspection, palpation, auscultation, and lastly percussion.
74
Q

Signs that are perceived by an examiner and can be seen, heard, measured, or felt are known as ___________ _________.

A

Objective data

75
Q
  1. Symptoms that are perceived by the patient are known as _____________ ____________.
A

subjective data

76
Q

A condition is which there is a lack of appetite resulting in the inability to eat is known as

A

Anorexia

77
Q

A condition of debility, loss of strength and energy, and depleted vitality is known as

A

Asthenia

78
Q

A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as

A

Bradycardia

79
Q

A condition in which a patient experiences bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood is known as

A

Cyanosis

80
Q

Discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls is known as

A

Ecchymosis

81
Q

Redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries is known as

A

Erythema

82
Q

A yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver is known as

A

Jaundice

83
Q

An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is known as

A

Orthopnea

84
Q

A symptom of itching and an uncomfortable sensation leading to an urge to scratch is known as

A

Pruritus

85
Q

A creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues is known as

A

Purulent drainage

86
Q

An abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats per minute is known as

A

Tachycardia

87
Q

An abnormally rapid rate of breathing that is seen in many disease conditions is known as

A

Tachypnea

88
Q

A condition in which there is a temporary loss of consciousness associated with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of the skin is known as

A

Syncope

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