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Physical Assessment > Unit Two Test > Flashcards

Unit Two Test Flashcards

1
Q

sources of data in Interview

A

primary and secondary

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2
Q

primary is

A

patient

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3
Q

secondary is

A

from family or chart

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4
Q

what are the phases of the interview

A

orientation
working
termination

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5
Q

begins at the introduction, knock on door and introduce self

A

orientation phase

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6
Q

collecting data, actually doing your physical care and planning nursing care

A

working phase

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7
Q

documented and saved data at end of assessment with patient

A

termination phase

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8
Q

physical examination is when you

A

gather by observation, look, listen, and feel

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9
Q

what are the types of physical assessment

A

comprehensive

focused and systemic specific

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10
Q

ongoing and head to toe are not assessments that are separate, they are part of the

A

comprehensive, focused and system specific

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11
Q

in depth assessment where you are manipulating the body to get a medical diagnosis from it (PA or NP usually do this)

A

comprehensive

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12
Q

obtain specific info based on pt admitting dx or potential problem (ex. shortness of breath- assess lungs and respiration, oxygenation, color of skin)

A

focused

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13
Q

focusing on only one system (we will do every system assessment)

A

system specific

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14
Q

how often do you have to come into the room is

A

ongoing

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15
Q

all assessments we do this in a systematic way to help us not leave anything out)

A

head to toe

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16
Q

what is the nursing process of physical assessment

A

assessment
nursing diagnosis
planning
evaluation

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17
Q

what are the 5 techniques for assessment

A 
inspection
palpation
percussion
auscultation
olfaction
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18
Q

observing is

A

inspection

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19
Q

touching is

A

palpation

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20
Q

listening by THUMPING is

A

percussion

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21
Q

listen with stethoscope is

A

auscultation

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22
Q

smelling is

A

olfaction

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23
Q

in assessment we use all senses except

A

taste!

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24
Q

when inspecting what should you do with body parts not being inspected

A

drape or cover body parts

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25
Q

what parts are needing additional lighting

A

eyes, ears, throat

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26
Q

what are you observing for

A

color, shape/symmetry, movement, position

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27
Q

what is considered light palpation

A

1cm or 1/2 in depth

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28
Q

what is considered deep palpation

A

4cm or 2in depth

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29
Q

what are the techniques of palpation

A

bimanual/ manual
dorsum of hand
palm or ulnar surface of hand
plamar surface of finger/finger pads

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30
Q

you palpate to assess

A

texture, resistance, resilience, mobility, temperature, thickness, shape and moisture

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31
Q

what is another word used for moist

A

diaphoric

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32
Q

where should you assess turgor

A

at clavicle

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33
Q

what are the 2 ways to percuss

A

direct and indirect

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34
Q

applied directly to body is

A

direct

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35
Q

applied through another or surface is

A

indirect

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36
Q

where do you typically percuss

A

over the stomach and the intestines

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37
Q

what are the characteristics of auscultation

A

frequency
loudness
quality
duration

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38
Q

of oscillations per second generated by a vibrating object

A

frequency

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39
Q

amplitude of a sound wave

A

loudness

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40
Q

descriptive is

A

quality

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41
Q

length of time that sound lasts is

A

duration

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42
Q

when using the stethoscope it is always best to

A

directly place it on skin

43
Q

best for LOW pitched sounds

A

bell

44
Q

best for HIGH pitch sounds

A

diaphragm

45
Q

olfaction is used to detect

A

abnormal and normal symptoms

46
Q

what should you clean between clients

A

stethoscope head and blood pressure cuffs

47
Q

what are the special considerations when assessing for the aged

A

may need to adjust position
may need to allow more time
may need to allow more space

48
Q

when is the health history taken

A

before physical exam

49
Q

what is the exception for taking height and weight

A

only need to take it upon admitted and not usually taken continuously unless patient has fluid filling

50
Q

when measuring circumference what is measured

A

head, chest, stomach, legs

51
Q

when should vital signs be taken

A

evry 4 hours unless noted otherwise

52
Q

what do lasix (diuretic) meds do to a patient

A

tend to make patient urinate more and expect weight to drop

53
Q

when a pt has swollen legs what should be done

A

elevation and TED hose

54
Q

blue skin=

A

not enough oxygenation

55
Q

yellow skin=

A

jaundice

56
Q

turgor is checked for

A

hydration status

57
Q

bright red bleeding of a wound should be

A

reported

58
Q

in integument what are you assessing

A

oxygenation, circulation, nutrition, tissue damage, hydration (skin nails and hair)

59
Q

if pt has been on bedrest pay extra attention to

A

skin over bony prominences such as elbows, coccyx, hips and heels

60
Q

if there is redness on skin what should you do

A

check for blanching

61
Q

fluid building (pooling in certain areas(

A

pitting edema

62
Q

how would you document pitting edema status

A

press until you feel bone and depending on how far deep finger goes is what you document

63
Q

terminal hair is

A

scalp, axillae, pubic, and beard

64
Q

vellus hair is

A

soft tiny hairs covering the body except palms and soles

65
Q

hair loss

A

alopecia

66
Q

excessive hair

A

hirsutism

67
Q

when the nail has long term oxygen deprivation (finger enlarges because it hasn’t been the normal growth

A

clubbing

68
Q

a pupil dilated in

A

the dark

69
Q

a pupil constricts in the

A

light

70
Q

when is the only time pupils will not react

A

if pt has cataracts, trauma, injury to head

71
Q

what is the pupillary reflex

A 
Pupils
Equal
Round
Reactive 
Light 
(Accommodation)
PERRLA
72
Q

abscess teeth can cause

A

heart disease

73
Q

clear liquid in ears is

A

cerebrospinal fluid (indicated head injury)

74
Q

low set ears=

A

downsyndrome

75
Q

red ears=

A

fever, ear infection, picking at ear

76
Q

extreme palor=

A

paleness (not getting enough oxygen, or cold)

77
Q

jugular vein distention usually indicates

A

high blood pressure

78
Q

COPD people cannot

A

recoil and have difficulty breathing (their level of carbon dioxide makes them take a breath)

79
Q

funnel chest=

A

indention (nothing wrong unless doing CPR)

80
Q

pigeon chest

A

structure of sternum the way it grows outward

81
Q

check for scoliosis by

A

bending over and touching toes

82
Q

kyphosis

A

hunchback

83
Q

type of breathing pattern where pt is going through a hard time of breathing (panting)

A

kussmauls

84
Q

why should you ask pt for history of smoking

A

history can cause lung damage and affect what we are hearing

85
Q

when assessing cardiovascular what is the PMI (point of maximum impulse)

A

5th intercostal space just medially to the left mid clavicular line)

86
Q

when should you listen to apical

A

if radius is abnormal or pt is taking digoxin (for qt intervals)

87
Q

sound associated with closing of mitral/tricuspid valves

A

lub or S1

88
Q

sound associated with the closing of the aortic/pulmonic valves

A

Dub or S2

89
Q 
pulse points 
0
1+
2+
3+
4+
A 
0= absent non palpable
1+= diminished, palpable
2+= strong, normal
3+= full, inceased
4+= bounding
90
Q

typically around feet and ankles; older adults and those who stand a lot

A

dependent edema

91
Q

venous insufficiency or R heart failure, fluid accumulates in tissue

A

pitting edema

92
Q

when assessing gastrointestinal what should you ask the patient to do

A

go to the bathroom before assessment

93
Q

in gastrointestinal assessment no deep palpation more interested in

A

the bowel sounds

94
Q

why do you palpate the abdomen last

A

palpation causes unneeded sounds

95
Q

what hinders abdomen exam

A

tense muscles

96
Q

what order should the assessment go

A

inspection, auscultation, percussion, palpation

97
Q

bowel sounds normal=

A

5-35 times per minute

98
Q

bowel sounds of hyperactive=

A

greater than 35 times per minute

99
Q

bowel sounds of hypoactive=

A

less than 5 times per minute

100
Q

bowel sounds of absense=

A

5 minutes

101
Q

areas of air are

A

stomach

102
Q

areas of solid masses

A

liver, intestines

103
Q

when should you use light palpation (1/2 in depth)

A

using palm of hand with fingers extended check

  • distended bladder
  • superficial masses
  • tenderness
104
Q

IV sites are NOT considered a wound it is a

A

access site

Physical Assessment (1 decks)

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