Physical Assessment

Question 1

conjunctivae

Answer 1

mucous membranes that line the eye ball (bulbar conjuctiva and inside surfaces of the eyelids (palpbral conjuctiva)

Question 2

outer part of the eye ball

Answer 2

sclera

Question 3

transparent layer than covers the iris and the pupil

Answer 3

cornea

Question 4

maxillary sinus

Answer 4

under eyes lateral to nose

Question 5

frontal sinus

Answer 5

above inner part of eyebrows

Question 6

Orientation deficit is a gap in the client’s awareness of person, place, or time.

Answer 6

Acute disorientation can be caused by infections, dehydration, low oxygen levels, medications, and other imbalances. Chronic disorientation can be present with some neurological disorders.

Question 7

sign of stroke

Answer 7

one-sided muscle weakness by instructing the client to squeeze both of your hands at the same time.

Question 8

vital signs: orientation deficit

Answer 8

vital signs such as increased temperature or decreased oxygen saturations can lead to changes in the client’s orientation.

Question 9

expected findings: skull

Answer 9

generally round with prominences in the frontal area anteriorly and the occipital area posteriorly

Expected protrusions are also found on the side of each parietal bone and the mastoid process behind each ear.

The head should be proportional in relation to the body and is typically held upright and midline to the trunk.

Question 10

expected findings: facial features

Answer 10

the palpebral fissures (the opening between the eyelids) and the nasolabial folds (creases from the nose to the corner of the mouth), should be symmetrical and the face should have a relaxed expression.

Question 11

expected variations: facial features

Answer 11

Slight asymmetry of facial features is expected. Dry, brittle hair and overall hair thinning are often related to aging.

Question 12

unexpected findings: facial features

Answer 12

significantly asymmetrical typically indicate a paralysis of one of the cranial nerves that control the facial muscles.

It can also be an indication that the client has had a stroke.

A tense facial expression could indicate anxiety or pain.

Question 13

unexpected findings: head

Answer 13

Lumps, protrusions, or sunken areas in the skull can indicate trauma to the head.

Ecchymotic areas on the skull or face can indicate the occurrence of recent trauma.

The presence of coarse facial hair on a female (e.g. hirsutism) can indicate a hormonal or endocrine disorder.

Question 14

unexpected findings: scalp

Answer 14

Lesions, or redness on the face or scalp can indicate the presence of a skin disorder or infection.

Hair loss can indicate conditions such as the presence of an autoimmune inflammatory disorder (alopecia areata, Lupus, conditions of the thyroid, a fungal infection [tinea capitus], effects from certain medications [chemotherapeutic agents], or stress).

Small oval white particles attached to the hair strands can indicate the presence of head lice (Pediculus humanus capitis).

Question 15

unexpected findings: eyes

Answer 15

Edema around the eyes (periorbital), cheeks, or overall facial edema can occur with trauma, infection, and heart problems.

Question 16

expected findings: eye assessment

Answer 16

The eyes should be placed parallel to one another on the face and aligned in the socket, with no protrusion or sunken appearance.

Eyebrows should be symmetrical and extend over the width of the eye. They should move symmetrically with changes in the client’s facial expression. The skin beneath the brows should be free of flakiness or lesions. Eyelashes should have an even distribution and a curved outward shape away from the eye.

The eyelids should be smooth and the same color as the surrounding skin without the presence of edema. The margins should be pink in color and rest along the eyeball surface. When open, the eyelids should cover no more than the top portion of the iris. The upper eyelid should come in contact with the lower lid when the eyes are closed.

Question 17

liver disease: eyes?

Answer 17

yellow sclera

Question 18

expected resting pupil size

Answer 18

3 to 5 mm

Question 19

unexpected findings: eye assessment

Answer 19

Unexpected eye positions include bulging eyes (exophthalmos) and crossed eyes (strabismus).

Eyebrows not extending beyond the outside of the eye (temporal canthus) can indicate an endocrine disorder.

If the client is unable to move their brows, they may have facial nerve damage.

Scaling or flaking of the skin in the eyebrows can indicate a skin disorder.

Redness of the eyelids can indicate the presence of an infection or inflammation.

Edema of the eyelids can be associated with trauma, or kidney or cardiac disease.

A drooping of the eyelid can be caused by edema or damage to one of the cranial nerves.

An inability to completely close the eyelids is associated with lid edema, nerve paralysis, excessively protruding eyeballs, and unconsciousness. This condition can lead to drying and damage of the cornea.

An overall coloring of the sclera that is yellow or green can be present if the client has liver disease.

A subconjunctival hemorrhage has clearly marked edges and is caused by activities that increase the pressure within the eye like coughing and vomiting.

Conjunctivitis is an inflammation of the conjunctiva causing redness and drainage, usually the result of a bacterial or viral infection, allergy, or chemical injury to the eye.

Unequal size pupils, both at rest and in reaction to the light test, can be a sign of a central nervous system injury as can pupils that are dilated and do not react to light.

Cloudy pupils indicate the presence of cataracts or a loss of transparency of the lens of the eye, which impairs the client’s vision.

In typical lighting, pupils that are dilated at rest (greater than 7 mm) can signify an eye disease or neurological disorder.

In typical lighting, pupils that are pinpoint at rest (less than 3 mm) commonly indicate opioid intoxication.

Question 20

strabismus

Answer 20

misalignment of the eyes

Question 21

subconjunctival hemorrhage

Answer 21

bleeding that occurs under the conjunctiva

Question 22

cataract

Answer 22

a cloudy pupil or a loss of transparency of the lens of the eye

Question 23

conjunctivitis

Answer 23

an inflammation of the conjunctiva causing redness and drainage

Question 24

Increased tearing with redness and lid edema typically indicates the presence of what?

Answer 24

seasonal allergies

Question 25

expected findings: ear

Answer 25

The auricle, or outer ear, should appear symmetric in size and placement.

The color of the client’s ear should be the same as the client’s face. Skin should be intact, with no lumps, edema, or lesions.

Some cerumen is usually visible at the opening to the outer ear canal. Cerumen can be a wide variety of colors and textures from grey-yellow to tan to black, moist and waxy to dry and flaky.

Question 26

expected variants: ear

Answer 26

​​​​​​​Unusually small, large, or atypically shaped ears are often a family trait.

Question 27

unexpected findings: ears

Answer 27

lients who have skin conditions such as eczema can have crusts and scaling on their ears.

Redness of the client’s ear is a sign of inflammation or fever.

Redness, edema, and purulent, or crusty drainage of the ear canal can indicate an infection.

Bright-red blood or watery drainage following a trauma can indicate a fracture to the base of the skull.

Clients who frequently ask you to repeat questions or provide an inappropriate response to a question can have a diminished sense of hearing. Other signs of hearing deficit include the client leaning toward you, turning their head toward you, or closely watching your lips while you speak.

Question 28

Watery clear or blood-tinged drainage from the canal can indicate the presence of?

Answer 28

presence of an existing skull fractures

Question 29

Edema, warmth, and pain in the ear or surrounding tissues indicate the presence of?

Answer 29

an infection

Question 30

expected findings: nose

Answer 30

symmetrical
same color skin as rest of face
nares mucosa should be smooth moist surface that is deeper color than oral mucosa
mucosa should be free of swelling, discharge, bleeding, or foreign bodies

Question 31

unexpected findings: nose

Answer 31

pale mucosa-allergies

mucoid discharge + bright red nasal mucosa- respiratory

infection
yellow or green discharge-infection in sinus cavity

watery discharge-skull fracture

Question 32

expected findings: mouth

Answer 32

moist, symmetrical, and smooth. Lips can range from pink to plum-colored, and are typically deeper in color than the surrounding facial skin.

The mucosa should appear glistening, smooth, and moist. Clients who have darker skin tones can have more darkly pigmented mucosa with areas of hyperpigmentation while clients who have lighter skin tones will have pink mucosa.

The hard palate, or roof of the mouth, is located in the anterior of the mouth. It is dome-shaped and whitish in color. The soft palate should be smooth and light pink.

Question 33

unexpected findings: mouth

Answer 33

A smooth or dark red swollen tongue can indicate low vitamin B12 levels.

Swelling of the gums with redness and bleeding can indicate the presence of gingivitis, which can lead to tooth loss if not treated.

A yellow discoloration of the hard palate can indicate liver disorder.

The presence of petechiae (small hemorrhages), lesions, edema or drainage on the hard or soft palate can indicate the presence of an infection.

A sore mouth with soft white plaques on the tongue or mucosa indicate an oral fungal infection called thrush. These plaques leave a red open area when rubbed off and are often found in immunocompromised clients

A client who has a sore throat can present with a red and edematous uvula and tonsillar pillars. Sometimes they will also have yellow exudate.

A painful round ulcer on the mucosa or lip with a white base surrounded by a red halo is known as a canker sore or an aphthous ulcer.

Question 34

what does a smooth and dark red swollen tongue indicate?

Answer 34

low vitamin B12 levels

Question 35

expected findings: neck

Answer 35

​​​​​​​The neck should be centered below the head. The neck muscles (trapezius and sternocleidomastoid) should appear symmetrical bilaterally. The trachea is positioned midline and above the suprasternal notch. There should be no lumps or swelling visible or palpable in the neck. The skin should be the same pigmentation as other skin areas and the area should be free of contusions or lesions.

should be able to have full ROM of neck w/o pain or difficulty

should be able to swallow without choking or difficulty

Question 36

unexpected findings: neck

Answer 36

Limited ability to move the neck or pain with neck movement can indicate a systemic infection in the spine or a musculoskeletal disorder.

A trachea that is shifted away from midline is associated with a mass in the neck or chest disorders.

A swelling on the anterior portion of the neck can indicate a disorder of the thyroid gland.

Visible lymph nodes can indicate an infection or possibly a malignancy (cancer).

Difficulty with swallowing can indicate an inflammation or central nervous system disorder.

Question 37

A swelling on the anterior portion of the neck can indicate a?

Answer 37

disorder of the thyroid gland.

Question 38

ptosis

Answer 38

drooping of the eye lid over the pupil and is often the result of edema or a neurological disorder.

Question 39

entropion

Answer 39

condition in which the eyelids roll inward and can cause the lashes to touch and irritate the conjunctiva and cornea.

Question 40

unexpected finding: respiratory

Answer 40

Clients who have chronic obstructive pulmonary disease (COPD) will sit in a tripod position with their body leaning forward and hands resting on their knees or a table to aid in expiration of carbon dioxide. When using this position, the client is using abdominal, intercostal, and neck muscles to facilitate breathing. They may exhale through pursed lips and may have difficulty talking.

Question 41

manifestations of hypoxia

Answer 41

anxious, agitated, or confused

Question 42

what does general pallor mean?

Answer 42

anemia, result in decreased oxygenation

darker skin to ashy tone

Question 43

if a client has scoliolis?

Answer 43

oxygen exchange can be compromised due to poor lung expansion

Question 44

what is barrel chest caused from>

Answer 44

COPD

Question 45

cheyne-stokes breathing

Answer 45

Cheyne-Stokes breathing can occur if the central nervous system is grossly affected by lack of oxygen or disease progression. It appears to have a respiratory “start-stop” breathing pattern. The client will have deeper breathing that may quicken, followed by hypoventilation and progress to apnea, a lack of respirations. This is an end-of-life breathing pattern.

Question 46

what is common in older clients with their spine?

Answer 46

kyphosis (hunchback)

Question 47

tracheal breath sounds

Answer 47

heard over the trachea of the anterior neck area

Question 48

bronchial breath sounds

Answer 48

heard to the right and the let of the trachea and larynx

auscultated over anterior chest side only

Question 49

bronchovesticular breath sounds

Answer 49

right and left major bronchi

first and second intercostal space

Question 50

vesicular breath sounds

Answer 50

over the anterior and posterior chest wall

Question 51

expected tracheal breath sounds

Answer 51

loud intensity and high pitch. Both inspiration and expiration duration of sounds are equal.

Question 52

expected bronchial breath sounds

Answer 52

loud intensity and high pitch. The client’s inspiration is a shorter duration than the expiration.

Question 53

expected bronchovesicular breath sounds

Answer 53

specially on the right—have a moderate intensity and pitch. Bronchovesicular inspiration and expiration duration are equal.

Question 54

expected vesicular breath sounds

Answer 54

a more intense and loud airflow in the upper anterior lobes but have a softer intensity with a low pitch throughout the other lobes. These breaths are soft-sounding like wind blowing through trees. Vesicular inspiratory sounds last longer than expiratory sounds.

Question 55

pleural friction rub

Answer 55

low-pitched, coarse, grating tone like rubbing two pieces of leather together. Pleural friction rub is heard on inspiration and expiration.

It is caused from inflammation of the pleura and is very painful.

Question 56

crackles

Answer 56

intermittent rattling, crackling, popping, or bubbling sound. These sounds can be fine and high-pitched or coarse and low-pitched and are not cleared by coughing. Various lung conditions, such as an increase in fluid, inflammation, or consolidations, can take up the space around not fully inflated alveoli and produce crackles.

Question 57

wheezes

Answer 57

made when air flows through narrowed airway passages. The client may have inspiratory wheezes, expiratory wheezes, or both.

Chronic conditions such as asthma or bronchitis can cause edema in the bronchioles

Question 58

rhonchi

Answer 58

continuous, low-pitched, snoring-type sound that can be heard with inspiration and expiration. It is caused by fluid, mucus, or a growth in larger airways. It can sometimes clear with coughing.

Question 59

stridor

Answer 59

high-pitched crowing sound that can be heard without a stethoscope. It is the result of upper airway obstruction caused by inflammation or a foreign body and can be life-threatening.

Question 60

The nurse is inspecting a client’s anterior chest. Which of the following findings should the nurse expect?

Answer 60

The ribs are sloping downward at an angle.

45 degrees

Question 61

A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?

Answer 61

tripod position

Question 62

Kassmaul breathing

Answer 62

consists of respirations that are abnormally deep, regular, and increased in rate

Question 63

what is an expected finding in mouth

Answer 63

large vein on the ventral surface of tongue

*underneath tounge

Question 64

tinnitus

Answer 64

high pitched ringing in the ears

Question 65

irrigate a leg wound. what PPE do you need?

Answer 65

gown, gloves, and goggles