Physical Assessment I

Question 1

If a tonsil is visible, the nurse would document a grade of…

Answer 1

1+

Question 2

If a tonsil is halfway between the tonsillar pillars and uvula, the nurse would document a grade of…

Answer 2

2+

Question 3

If a tonsil is touching the uvula, the nurse would document a grade of…

Answer 3

3+

Question 4

If a tonsils are touching or “kissing” the other, the nurse would document a grade of…

Answer 4

4+

Question 5

A whispered voice assessment tests for…

Answer 5

gross hearing

Question 6

The Weber and Rinne tuning fork test measures…

Answer 6

hearing by air conduction/bone conduction in which the sound vibrates through the cranial bones to the inner ear

Question 7

The Snellen chart measures…

Answer 7

visual acuity

Question 8

The Confrontation Test measures…

Answer 8

peripheral vision

Question 9

The Diagnostic Positions Test measures…

Answer 9

EOM’s

Question 10

Nystagmus is defined as

Answer 10

a fine oscillating movement of the eye. expected when assessed at extreme lateral gazes.

Question 11

Consensual response of the pupil means…

Answer 11

simultaneous constriction of the other pupil when a light is shined in the eye.

Question 12

When assessing accommodation of the eye the expected response would be…

Answer 12

pupillary constriction and convergence of the axes of the eyes

Question 13

The acronym PERRLA means…

Answer 13

pupils equal, round, reactive to light, and accommodation

Question 14

Define flexion:

Answer 14

bending a limb at a joint

Question 15

Define extension:

Answer 15

straightening a limb at a joint

Question 16

Define abduction:

Answer 16

moving a limb away from the bodies midline

Question 17

Define adduction:

Answer 17

moving a limb toward the bodies midline

Question 18

Define pronation:

Answer 18

turning the forearm so the palm is down

Question 19

Define supination:

Answer 19

turning the forearm so the palm is up: think holding a can of soup

Question 20

Define inversion:

Answer 20

moving the sole of the foot inward at the ankle

Question 21

Define eversion:

Answer 21

moving the sole of the foot outward at the ankle

Question 22

Define rotation:

Answer 22

moving the head around a central axis

Question 23

Define crepitation:

Answer 23

an audible and palpable crunching or grating that occurs with movement of the joint

Question 24

Define crack:

Answer 24

heard as a tendon or ligament slips over the bone during motion

Question 25

Define scoliosis:

Answer 25

lateral S shaped curvature of the spine

Question 26

Define kyphosis:

Answer 26

enhanced thoracic curve: think Hunchback of Notre Dame

Question 27

Define lordosis:

Answer 27

pronounced lumbar curve: think pregnancy or obesity

Question 28

If muscle strength is described as "full ROM against gravity, full resistance," the nurse would document this as a...

Answer 28

Grade 5

Question 29

If muscle strength is described as "full ROM against gravity, some resistance" the nurse would document this as a...

Answer 29

Grade 4

Question 30

If muscle strength is described as "Full ROM with gravity" the nurse would document this as a...

Answer 30

Grade 3

Question 31

If muscle strength is described as "Full ROM with passive motion" the nurse would document this as a...

Answer 31

Grade 2

Question 32

If muscle strength is described as "slight contraction" the nurse would document this as a...

Answer 32

Grade 1

Question 33

If muscle strength is described as "no contraction" the nurse would document this as a...

Answer 33

Grade 0

Question 34

The order of examination for the musculoskeletal system is...

Answer 34

Inspection, Palpation, Range of Motion, and Muscle Testing

Question 35

Define active range of motion.

Answer 35

The range of motion that can be achieved when opposing muscles contract and relax, resulting in joint movement. The patient can complete ROM without help.

Question 36

Define passive range of motion.

Answer 36

The space in which a part of your body can move when someone or something is creating the movement. Such as movement of a joint with physical therapy. The patient has assistance.

Question 37

Define circumduction.

Answer 37

Moving a joint in a circle.

Question 38

Techniques used in physical assessment are completed in the following order for patient safety and comfort.

Answer 38

1. Inspection 2. Palpation 3. Percussion 4. Auscultation

Question 39

Techniques used for the abdominal assessment are always completed in this order.

Answer 39

1. Inspection 2. Auscultation 3. Percussion 4. Palpation

Question 40

Pulses are graded on a scale of 0-4+ Identify the scale

Answer 40

4+ Bounding 3+ Increased 2+ Expected finding 1+ Weak 0 Absent

Question 41

Define the acronym ABCDEE for assessing skin lesions

Answer 41

A-Assymetry B-Border irregularity C-Color D-Diameter <6mm E-Evolution E-Elevation

Question 42

Define 1+ edema

Answer 42

mild pitting; slight indentation; no perceptible swelling of the leg

Question 43

Define 2+ edema

Answer 43

Moderate pitting. indentation subsides rapidly

Question 44

Define 3+ edema

Answer 44

Deep pitting; indentation remains for a short time; leg looks swollen

Question 45

Define 4+ edema

Answer 45

Very deep pitting; indentation lasts a long time; leg is grossly swollen and distorted

Question 46

Define alert

Answer 46

Awake or readily aroused, oriented, fully aware of all stimuli

Question 47

Define lethargic

Answer 47

Not fully alert, drifts off to sleep when not stimulated

Question 48

Define obtunded

Answer 48

Sleeps most of the time. difficult to arouse

Question 49

Define Stupor or Semi-coma

Answer 49

Spontaneously unconscious, responds only to vigorous shake or pain

Question 50

Define coma

Answer 50

completely unconscious. makes no response to pain or to stimuli