Physical Assessment Flashcards
A community health nurse is performing a skin assessment on a patient. The nurse discovers a dark, irregular area approx 1-2 cm on patient’s back that was not there last year. What should the nurse do next?
Refer the patient to a dermatologist
The nurse has the following tasks: Administer medication, perform an assessment, feed a patient, take vital signs, and give a bed bath. What tasks can the nurse delegate to the CNA?
feed, vitals, bed bath
The nurse knows that the patient is experiencing left sided heart failure based on which of the following assessments?
- Pitting leg edema
- Liver enlargement
- Dyspnea
- Cheyne-stokes respirations
- irregular or rapid pulse
edema, dyspnea, irregular pulse
The nurse is charting a skin assessment on a newly admitted patient. The patient has a large bruise on their right forearm from a fall. The nurse should chart this using what terminology?
ecchymyosis
The nurse is performing an assessment of a patient’s abdomen. Upon palpation, the nurse feel an abnormal lump in the LUQ (left upper quadrant) that is extremely painful for the patient. The nurse suspects she is palpating which of the following?
inflamed spleen
A 73-year-old patient is diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?
buccal cyanosis and capillary refill greater than 3 seconds
During the nursing assessment, which data represent information concerning health beliefs?
A Family role and relationship patterns
B Educational level and financial status
C Promotive, preventive, and restorative health practices
D Use of prescribed and OTC medications
C
The nurse is acquiring information from a patient in the emergency department. Which is an example of biographic information that may be obtained during a health history? A The chief complaint B Past health status C History immunizations D Location of an advance directive
past health status
When assessing the lower extremities for arterial function, which intervention should the nurse perform? A Assessing the medial malleoli for pitting edema B Performing Allen's test C Assessing the Homans' sign D Palpating the pedal pulses
D
A newly hired nurse is excited to perform her very first physical assessment with a 19-year-old patient. Which assessment examination requires the nurse to wear gloves? A Breast B Integumentary C Opthalmic D Oral
D
The nurse is about to perform a Romberg test to a patient. To ensure safety for the patient, which intervention should the nurse implement?
A
Allowing the patient to keep his eyes open
B
Having the patient hold on to furniture
C
Letting the patient spread his feet apart
D
Standing close to provide support
D
Which assessment data should the nurse include when obtaining a review of body systems?
A
Brief statement about what brought the patient to the health care provider
B
Patient complaints of chest pain, dyspnea, or abdominal pain
C
Information about the patient’s sexual performance and preference
D
The patient’s name, address, age, and phone number
B
For which time period would the nurse notify the health care provider that the patient had no bowel sounds? A 2 minutes B 3 minutes C 4 minutes D 5 minutes
D
Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse? A aortic arch B pulmonic area C tricuspid area D mitral area
D
A patient was scheduled for a physical assessment. When percussing the patient's chest, the nurse would expect to find which assessment data as a normal sign over his lungs? A Dullness B Resonance C Hyperresonance D Tympany
B
