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Physical Assessment > Week #2: Physical Assessment > Flashcards

Week #2: Physical Assessment Flashcards

1
Q

In a comprehensive assessment, which data about the patient will most likely be collected? 4x

A
  1. Present level of wellness
  2. Changes in life patterns
  3. Sociocultural roles
  4. Mental and emotional reactions to illness
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2
Q

What assessment is used as a general health assessment?

A

Nursing physical assessment

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3
Q

Gathering biographical information from a patient is a component of what assessment?

A

Comprehensive

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4
Q

Which assessment incudes a review of diagnostic data? (Lab or radiologic)

A

Comprehensive

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5
Q

Checking for the patients physical health patterns, food and drug allergies and medication history are all components of what assessment?

A

Comprehensive

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6
Q

When obtaining an holistic evaluation, this is most likely what kind of assessment?

A

Nursing physical assessment

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7
Q

The _______ ______ assessment is used to gather data about the patient.

A

Nursing physical

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8
Q

The nursing physical assessment focuses on functional abilities and responses to ________ and _______.

A

Illnesses and stressors

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9
Q

Name the four types of physical examinations.

A
  1. Comprehensive
  2. Focused
  3. System-specific
  4. Ongoing
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10
Q

Which type of physical examination is performed on admission?

A

Comprehensive

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11
Q

This type of physical examination is limited to one body system.

A

System-specific

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12
Q

Which of the following type of assessment would a nurse perform on a a patient who is having problems breathing due to COPD?

A. Comprehensive health assessment
B. Focused-assessment
C. Initial head-to-toe
D. None of the above

A

B

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13
Q

What are the two types of data?

A
  1. Objective
  2. Subjective
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14
Q

Observation of measurements of a patients health status is which type of data?

A

Objective data

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15
Q

The patients verbal descriptions of their health problems.

A

Subjective data

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16
Q

The size or condition of a patients wound or the description of an observed behavior, vital signs are all examples of which form of data?

A

Objective

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17
Q

A patient rates his level of back pain, expresses his feelings and perceptions. Based off of the information, what type of data is this considered?

A

Subjective

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18
Q

When preparing the environment, what are the five things to consider?

A
  1. Privacy
  2. Noise
  3. Enable visualization
  4. Temperature
  5. Equipment
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19
Q

What are the four steps to promise client comfort?

A
  1. Develop report
  2. Explain the procedure
  3. Respect cultural differences
  4. Proper positioning
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20
Q

What are 6 major skills used within a physical assessment?

A
  1. Interview
  2. Inspection
  3. Palpating
  4. Percussion
  5. Auscultation
  6. Olfaction
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21
Q

Interview techniques include observation and four types of questions, what are they?

A
  1. Direct Closed-ended
  2. Open-ended
  3. Leading
  4. Probing
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22
Q

Watching facial expressions and body language is an interview technique of?

A

Observation

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23
Q

_________ questions guide the patient to a specific topic.

A

Leading

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24
Q

________ questions let you dig deeper on a topic you are on.

A

Probing

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25
Q

When interviewing a patient about a fall, a ________ question would be, “Did you hit your head?” If yes, _______ questions would follow up with would be, “Did you lose consciousness at all? Are you bleeding? Do you have a headache?”

A

Leading
Probing

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26
Q

Physical assessment technique questions: _________ is the use of sight to gather data.

A

Inspection

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27
Q

Inspection is used throughout the _________ _______.

A

Physical examination

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28
Q

What are the three tools used to enhance inspection?

A
  1. Otoscope
  2. Ophthalmoscope
  3. Penlight
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29
Q

Use of touch to gather data

A

Palpation

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30
Q

An example of examining the patients skin color, gait, general appearance and behaviors are all examples of which physical assessment technique?

A

Inspection

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31
Q

Physical assessment technique questions: ________ begins with light pressure, moving to deep palpation.

A

Palpation

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32
Q

Physical assessment technique questions: when performing palpitations, the fingertips are used to perform?

A

Tactile discrimination

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33
Q

Physical assessment technique questions:
When you’re palpating to obtain a temperature determination, which part of your hand is being utilized?

A

Dorsum

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34
Q

Physical assessment technique questions: when palpating for a general area of pulsation, which part of your hand is being used?

A

Palm

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35
Q

Physical assessment technique questions: when grasping a patient, you are using both, your fingers and your thumb for a ______ _______.

A

Mass evaluation

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36
Q

Tapping on skin to elicit sound.

A

Percussion

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37
Q

Physical assessment technique questions: there are two different ways to perform percussion, what are they?

A

Direct and indirect

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38
Q

This physical assessment technique is useful for assessing abdomen, lungs, underlying structures. An example would be a distended bladder.

A

Percussion

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39
Q

When practicing percussion, you’re listening to the sounds. Dull sounds indicate a ______ structure below and hallow sounds which indicates ______ ______ spaces are below.

A

Solid
Air filled

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40
Q

Physical assessment technique questions: Use of hearing to gather assessment data is what?

A

Auscultation

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41
Q

There are two types of auscultation, what are they?

A
  1. Direct
  2. Indirect
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42
Q

Physical assessment technique questions: In regards to auscultation, listening without an instrument is called ______ auscultation, and use of a stethoscope to listen is called ______ auscultation.

A

Direct

Indirect

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43
Q

Physical assessment technique questions: when utilizing a stethoscope, which part of the stethoscope has a high pitch sound? And which part of the stethoscope has low-pitched sounds?

A

Diaphragm and Bell

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44
Q

The nurse would be able to gather the most complete data about the clients pedal edema using the assessment skill of:

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

Although inspection would alert the nurse to the presence of edema, palpation will determine the degree to which it has occurred.

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45
Q

When performing a physical examination on a toddler, perform the ______ _______ last.

A

Invasive procedure

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46
Q

ADL’s

A

Activity of daily living

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47
Q

Ankle swelling is a symptom of which heart condition?

A

Congestive heart failure

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48
Q

The general survey begins at first _______.

A

Contact

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49
Q

Speech based: Inappropriate or illogical responses may be associated with _______ _______.

A

Psychiatric Disorders

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50
Q

Speech based: Difficulty speaking or changes in voice quality may indicate a ________ problem.

A

Neurological

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51
Q

Speech based: rapid speech may be a sign of ______ or use of _______.

A

Anxiety

Stimulants

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52
Q

Speech based: hoarseness of the voice could indicate _________ of the throat.

A

Inflammation

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53
Q

Speech based: slow speech may be due to what three things?

A
  1. Depression
  2. Sedation
  3. Neurological disorders
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54
Q

Speech based: a foreign accent with hesitancy and or sparse verbalization may signal a _______ _______ and may need an interpreter.

A

Language barrier

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55
Q

Mental state indicates what two things?

A

LOC
Confusion

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56
Q

Dressing/grooming/hygiene tells us about ability to care for themselves is considered an impression of a client undergoing a _______ survey.

A

General

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57
Q

Age modifications for PA: show approval and develop rapport

A

School-age children

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58
Q

Age modifications for PA: provide privacy

A

Adolescents

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59
Q

Age modifications for PA: allow independence

A

School age children

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60
Q

Age modifications for PA: address concerns that they are normal

A

Adolescents

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61
Q

Age modifications for PA: allow child to help with examination

A

Preschoolers

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62
Q

Age modifications for PA: allow to explore and/or sit on parents lap, offer choices and use praise

A

Toddlers

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63
Q

SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the first S stand for?

A

Sleep disorders

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64
Q

SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the P stand for?

A

Problems with eating or feeding

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65
Q

SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the I stand for?

A

Incontinence

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66
Q

SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the C stand for?

67
Q

SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the E stand for?

A

Evidence of falls

68
Q

SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention. What does the S stand for?

A

Skin breakdown

69
Q

Pain will increase 4 vital signs, what are they?

A
  1. BP
  2. PULSE
  3. TEMPERATURE
  4. RESPIRATIONS
70
Q

A client hospitalized with renal calculi (kidney stones) complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the clients vital signs, which include:

  1. Decreases pulse rate
  2. Increased blood pressure
  3. Decreased respiratory rate
  4. Decreased temperature
71
Q

A nurse is routinely monitoring a patients BP. What should the nurse do first when the assessment reveals a change in the patients blood pressure?

A. Report the change to the charge nurse
B. Document the observed change
C. Notify the health-care provider
D. Obtain the other vital signs (HR, Temp, etc.)

72
Q

When assessing a patients vital signs, the nurse understands that an essential principal of vital signs assessment is (select all that apply:

  1. Comparing the vital signs to the normal ranges for the patients age.
  2. Comparing a patients baseline of prior viral signs to the current reading.
  3. Asking the patient if he or she remembers the last set of vital signs.
  4. There is no need to compare current vital signs to previous vital signs
73
Q

A female patient, age 48, comes to the clinic with complaints of dizziness and a frontal headache. She tells you she is under a lot of stress because her husband was recently laid off. She is 5’4 and weighs 150 lb. You take her blood pressure and it is 178/100. When you tell her the blood pressure reading, she says, “This cannot be right! I usually run 100/60.” What should be your next action?

  1. Tell the patient that stress can raise BP so that must be it.
  2. Wait 2 minutes and retake the blood pressure in the other arm.
  3. Call in the health-care provider to retake the BP.
  4. Document the blood pressure as high.
74
Q

When you obtain a BP measurement on a patient that resulted in a high measurement, wait for about _____ minutes and retake the blood pressure in the opposite arm; document the _______ of the two blood pressure readings.

75
Q

The purpose of inspecting and palpating the head is to assess for normal ______ and ______ of the head.

A

Shape and size

76
Q

When inspecting a patients head, what is the equipment that needs to be used?

77
Q

When performing an inspection and Palpation for a patients head, you must inspect the patients head for what four things?

A
  1. Shape
  2. Size
  3. Configuration
  4. Movement
78
Q

When performing Palpation for a patients head, you must palpate it for what three things?

A

Tenderness

Masses or depressions

79
Q

A disorder associated with excess growth hormone, will cause a patient to have a large head. Occurs in adolescence or adult patients.

A

Acromegaly

80
Q

An abnormally small head size in infants, is caused by a variety of genetic and environmental factors. What is this called?

A

Microcephaly

81
Q

________ may be the result of trauma, surgery, neuromuscular disorder, paralysis, or congenital deformity.

82
Q

In infants and children, a head that is growing disproportionately faster than the body may be a sign of ___________.

A

Hydrocephalus

83
Q

An accumulation of excessive cerebrospinal fluid.

A

Hydrocephalus

84
Q

All children between the ages of ________ months and ______ years old are considered children.

A

24 months
11

85
Q

An adolescent age ranges from ______ years to ______ or ______.

A

12
16 or 18

86
Q

Hair changes can be related to what 4 things?

A
  1. Diet
  2. Stress
  3. Infection
  4. Endocrine disorders
87
Q

What three things do you look at when performing an inspection on the general condition of hair?

A
  1. Amount
  2. Distribution
  3. Cleanliness
88
Q

What two things are you observing when performing a general condition of the scalp?

A
  1. Hair color
  2. Hair texture
89
Q

Hair loss along the temples and in the center of the scalp is considered a normal balding pattern in men and is largely genetically based.

90
Q

________ alopecia can be caused by chemotherapy for the treatment of cancer, by nutritional deficiencies, or by endocrine disorders.

91
Q

Patchy hair loss may be caused by a fungal infection of the scalp, hair pulling, constant wearing of caps. A benign autoimmune disorder.

A

Alopecia Areata

92
Q

Pediculosis

93
Q

When assessing for visual acuity, what equipment is being used?

A

Snellen chart

94
Q

When assessing for visual acuity, the patient stands ______ ft away from the Snellen chart.

95
Q

When assessing for visual acuity, have the patient cover the ______ eye and start reading from the top to the bottom, out loud.

96
Q

When performing for visual acuity, ask about what two things?

A

Glasses or contacts

97
Q

Normal distant visual acuity is _______/_______.

98
Q

Assessing visual acuity: The higher the _________ means poorer distant visual acuity.

A

Denominator

99
Q

Nearsightedness

100
Q

Diminished distant vision

101
Q

What is the score resulting in legal blindness?

102
Q

What equipment do you use to assess for color blindness?

A

Ishihara plate

103
Q

Yellow ________ ________ may be seen with an elevated bilirubin.

A

Icteric Sclera

104
Q

PERRLA

A
  1. Pupils
  2. Equal
  3. Round
  4. Reactive to…..
  5. Light
  6. Accommodation
105
Q

________ is a growth or thickening of conjunctiva from the inner canthus toward the iris.

106
Q

An everted eyelid, is commonly seen in older adults secondary to loss of skin tone. It can lead to excessive dryness of the eyes.

107
Q

Inverted eyelid, can lead to corneal damage.

108
Q

Drooping of the lid, may be seen in clients who have experienced a stroke or Bell’s palsy.

109
Q

CVA (stroke)

A

Cerebrovascular accident

110
Q

Ptosis, or drooping of the lid, may be seen in clients who have experienced a ________ or _____ ______.

A

Stroke
Bell’s palsy

111
Q

Paralysis of the facial
Nerve

A

Bell’s Palsy

112
Q

When inspecting pupil size and consensual response, you must stand in front of the patient, and use the penlight to inspect the pupils for what three things?

A
  1. Color
  2. Shape
  3. Symmetry
113
Q

When performing an inspection of pupil size and consensual response, you are to measure the size of each pupil in ________.

A

Millimeters

114
Q

Inspecting _____ _______ and _______ response is to assess the pupillary light reflex that controls the diameter of the pupil, and to assess the integrity of the optic pathways (consensual response).

A

Pupil Size
Consensual

115
Q

Patient focuses on a far object and then focuses on near objects, in response, the patients pupils should get smaller for focusing on close objects.

This is an example of testing for ________.

A

Accommodation

116
Q

Testing for ______ _______, is to assess for weakness or problems with the ocular muscles.

A

Ocular motility

117
Q

When performing a test for ocular motility, use a finger or an object in your hand about _____to_______ inches from the patients face.

118
Q

When performing a test for ocular motility, move the object in six different positions using a wide ____ or a _____ pattern.

119
Q

Normal ear size ranges from _____ cm to ____ cm.

120
Q

Skin turgors refers to ________ of the skin.

121
Q

Ringing or a buzzing sound in the ears

122
Q

________ is the perception of sound when no actual external noise is present; it is commonly referred to as “ringing in the ears!”

123
Q

When inspecting the ears, what two tests are performed?

A
  1. Weber and Rinne tests
  2. Romberg test
124
Q

When performing an inspection on a patient ear, start assessing them during the first encounter, noting whether “_________ _______” is intact.

A

Conversational hearing

125
Q

A ______ implant bypass damaged portions of the ear and directly stimulates the auditory nerve.

126
Q

Inspecting and palpating the nose, purpose is to check for ______, _______ or ______.

A

Tenderness, deviation or inflammation

127
Q

Nasal drainage

128
Q

Nose bleed

129
Q

When inspecting the mouth, what tools are used?

130
Q

Dry mouth with decreased saliva. Many medications can cause dry mouth.

A

Xerostomia

131
Q

Enlargement of the thyroid gland.

132
Q

When inspecting the neck, the neck should be slightly ________.

A

Hyperextended

133
Q

JVD

A

Jugular vein distension

134
Q

Skin turgor under <3 sec is considered _________.

A

dehydration

135
Q

Loss of ability to understand or express spoken or written language.

136
Q

Person has difficulty coordinating and organizing words into sentences.

137
Q

What are the three forms of Dysphasia:

A
  1. Receptive
  2. Expressive
  3. Global
138
Q

Dysphasia: difficulty in comprehension

139
Q

Dysphasia: deficits in comprehension, naming, and speech production

140
Q

Dysphasia: difficulty in putting words together to make meaning

A

Expressive

141
Q

Able to open eyes but is drowsy and falls asleep readily.

142
Q

Client responds to light shaking but can be confused and slow to respond.

143
Q

Client requires painful stimuli (sternal rub or pinch) to achieve a brief response.

144
Q

No response to repeated painful stimulus

145
Q

MMSE

A

Mini Mental State Examination

146
Q

AVPU

A

Level of arousal/stimuli response

147
Q

BMR

A

Basal metabolic rate

148
Q

The MMSE is used to test for complaints of problems with _______ or other _______ _______.

A

Memory

Mental abilities

149
Q

What three things can you look at when obtaining a patients circulation?

A
  1. Pulse
  2. Temperature
  3. Capillary refill
150
Q

When obtaining a patients sensation levels, you must touch their ______/_________ to see if they can feel it

A

Fingers and toes

151
Q

What are the three major signs of a stroke?

A
  1. Face droops
  2. Arm weakness
  3. Speech difficulty
152
Q

Name two types of spinal deformity.

A

Scoliosis and Kyphosis

153
Q

Crackling skin caused by the air in the SQ tissue

154
Q

A Barrel chest is a result from ______.

155
Q

Funnel chest is more common in _______ (gender)

156
Q

______ chest is a protrusion of the sternum with a backward sloping of the ribs.

157
Q

Is difficulty or inability to breathe when lying down. Pt’s with respiratory or cardiac problems

158
Q

Hemoptysis

A

Blood in phlegm.

159
Q

Inspiration should be _____ times longer than expiratory phase.

160
Q

Shortness of breath with activity

A

Exertional Dyspnea

161
Q

High pitched musical sounds, usually with increased expiration. Wheezes.

162
Q

Course crackles

163
Q

Fluid in the alveoli causes a ______ sounds.

Physical Assessment (2 decks)

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