question

Melena

answer

Black, tarry stools

question

Edema

answer

fluid accumulation, swelling

question

alopecia

answer

loss of hair

question

ptosis

answer

drooping of eyelid over the pupil

question

petechiae

answer

tiny, pinpoint red spots on the skin

question

kyphosis

answer

curvature of the thoracic spine

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jaundice

answer

yellow-orange discoloration

question

induration

answer

a hardened area

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bruit

answer

blowing, swishing sound in blood vessel

question

erythema

answer

a red discoloration

question

what are the 5 skills used in physical assessment ?

answer

-Inspection: use of vision and hearing to detect characteristics of body parts and functions -Palpation: use of the hands to touch body parts to determine temperature , texture, position, and movement -Percussion: Striking the body surface with the finger to produce a vibration and elicit sounds -Auscultation: Listening to sounds created in the body organs -Olfaction: Use of smell to determine the presence of characteristic odors

question

Physical and behavioral findings that may indication child sexual abuse

answer

-genital discharge, bleeding, pain, itching -difficulty sitting or walking -foreign bodies in genital tract or rectum -problems eating or sleeping -fear of certain people or places -regressive or acting out behavior -preoccupation with own genitals

question

Physical and behavioral findings that may indication of domestic violence

answer

-injuries and trauma inconsistent with reported cause -multiple injuries, burns, bites -old and new fractures -eating or sleeping disorders -anxiety, panic attacks -low self esteem -depression , sense of helplessness -attempted suicide

question

Physical and behavioral findings that may indicate older adult abuse:

answer

-injuries and trauma inconsistent with reported cause -bruises, hematomas, burns, fractures -prolonged interval between injury and treatment -depended on caregiver -physically and or cognitively impaired -combative, belligerent

question

A patient has an area of discomfort. The nurse will examine this area:

answer

last

question

When using the stethoscope, high pitched sounds are heard best with a :

answer

diaphragm of the stethoscope

question

To inspect an ault patients ear canal, the nurse pulls the auricle :

answer

up and back

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the position to place the patient in for a genital examination is:

answer

dorsal recumbent position

question

identify what a nurse is able to assess in a general survey of a patient :

answer

-primary health problems -behavior and appearance -hygiene, skin condition, and body image: emotional state; recent changes in weight: and developmental status

question

a weight gain of 5 lbs or 2.2 kg/day indicates:

answer

fluid retention

question

What techniques are appropriate when assessing patients of different ages?

answer

-Speaking privately with adolescents about their concerns -providing time for children to play -performing the examination for an older adult to finish is as quickly as possible

question

patients older than 65 years should be instructed to have yearly eye examinations:

answer

true

question

a nurse is preparing to perform a skin assessment for an average adult patient. Techniques?:

answer

-using disposable gloves to inspect lesions -looking for coloration changes by checking the tongue and nail beds

question

During a physical examination, a nurse notes that the patient appears to be very anxious . The nurse should:

answer

-stop the examination, explain what is happening, ask the patient how he/she is doing, and postpone the procedure, if indicated

question

One example of a test for colorectal cancer is:

answer

-fecal immunochemical test (FIT) -fecal occult blood test (FOBT -colonoscopy -barium enema

question

three best positions that a patient may be places in for cardiac assessment:

answer

-supine -sitting -left lateral recumbent

question

identify signs and symptoms that a patient may have if he or she has cardiopulmonary disease:

answer

-chest pain or discomfort , palpations, excess fatigue , cough, dyspnea, edema of the feet, cyanosis, fainting, or orthopnea

question

what are the risk factors associated with osteoporosis:

answer

-smoking -a history of falls -a history of Cushing disease -a thin, light body frame

question

identify at least two techniques that are used in assessment of the lymph nodes:

answer

the patient relaxes with the neck flexed slightly forward. Inspect and palpate both sides of the neck for comparison. During palpation either face or stand to the side of the patient for easy access to all nodes. Using the pads of the middle three fingers of each hand, gently palpate in a rotary motion over the nodes To palpate supraclavicular nodes, ask the patient to bend the head forward and relax the shoulder. Palpate these nodes by hooking the index and third finger over the clavicle, lateral to the sternocleidomastoid muscle. Palpate the deep cervical nodes only with the fingers hooked around the sternocleidomastoid muscle Axille: Palpate the axillary nodes with the fingertips gently rolling soft tissue. Normally lymph nodes are not palpable. Note the number, consistency, mobility and size of palpable nodes

question

continuous dilation of the pupils is found with the patient experiencing:

answer

-neurological pathologies, glaucoma, opioid withdrawal and trauma, or taking ophthalmic medication

question

an expected response when testing the pupils for accommodation is:

answer

converge and accommodate by constricting when looking at close objects. The pupils response are equal

question

what is used to weigh the following patients? a. newborn infant b. mobile adult

answer

a. basket or platform scale b. a platform scale

question

the primary nurse tells the student that the patient is experiencing tinnitus. The student expects that the patient will describe:

answer

ringing in the ears

question

Three possible causes of hearing loss are:

answer

deterioration of the cochlea and thickening of the tympanic membrane in older adults , and ototoxicity resulting from high maintenance doses of antibiotics

question

To assess for a pulse deficit, the nurse should:

answer

-auscultate the apical pulse first and then immediately asses the radial pulse. Assess the apical and radial rates at the same time when two examiners are present. when a patient has a pulse deficit, the radial pulse is slower than the apical

question

An irregular pulse is counted for _____ seconds:

answer

1 min

question

Risk factors for breast cancer:

answer

-recent use of oral contraceptives -family history -childless

question

The correct sequence for the abdominal exam is :

answer

inspection, auscultation, palpation, percussion

question

Bowel sounds usually occur _____/min:

answer

5 to 35 times/min

question

Absent bowel sounds can result from :

answer

lack of peristalsis, possibly because of bowel obstruction, paralytic ileum, or peritonitis

question

When teaching the patient about the signs and symptoms of prostate cancer , the nurse should include what information :

answer

weak or interrupted urine flow, an inability to urinate, difficulty in starting or stopping the urine flow, polyuria, nocturia, hematuria, dysuria, or continuing pain the lower back , pelvis, or upper thighs

question

How can the nurse test recent and past memory ?:

answer

asking the patients to recall by repeating a series of numbers in the order they are presented or in reverse order. Patients normally recall five to eight digits forward or four to six digits backward. Another test for recent memory involved asking the patient to recall events occurring during the same day. To assess past memory, ask the patient to recall the maiden name of the patients mother, a birthday, or special date in history

question

A patient is suspected of substance abuse. What physical findings would be found on the skin :

answer

-spider angiomas -red, dry areas -burns on the fingers

question

a patient with ascites will have :

answer

-distended abdomen, taut skin, bulging flanks

question

A nurse is assessing a patients nail beds. An expected finding is indicated by :

answer

a 160 degree angle between the nail plate and nail

question

A young adult women arrives at the family planning center for a physical examination. For this patient with mature breasts, the nurse expects to find:

answer

nipples project and areolae have receded

question

The presence of anemia is accompanied by the nurses finding of :

answer

pallor

question

pallor :

answer

an unhealthy pale appearance

question

A patient with asthma goes to urgent care. A nurse ausculatates lungs and hears rhonchi , these sounds are described as :

answer

loud, low pitched , and coarse

question

A patient is admitted to hospital with peripheral vascular problem. A nurse is performing the initial assessment of the patient. While assessing the lower extremities , the nurse is alert to venous insufficiency as indicated by:

answer

marked edema

question

A nurse is performing a complete neurological assessment on a patient after a cerebrovascular accident (CVA/stroke). To assess cranial nerve III, the nurse:

answer

measure the pupil reaction to light and accommodation

question

To asses cranial nerve X, the nurse should ask the patient to :

answer

say "ah"

question

While completing a physical examination , a nurse assesses and reports that a patient has a petechiae. The nurse has found a :

answer

pinpoint-size , flat, red spots

question

Patient has hyperthyroid disorder. The nurse anticipates that an examination of the eyes will reveal :

answer

exophthalmos

question

Exophthalmos:

answer

bulging eyes

question

A nurse anticipates that the color of the eardrum should appear :

answer

pearly gray

question

A patient has an increased anteroposterio diameter of the chest. The nurse should inquire specifically about the patients history of :

answer

smoking

question

When auscultation a patients chest, a nurse hears what appears to be an S3 sound. This is an expected finding if the patient is:

answer

10 yrs old

question

patient -bed rest for long period of time. Possibily of patient developed phlebitis. The nurse assesses for the presence of this condition by:

answer

checking the appearance and circumference of the lower legs

question

A nurse uses this method to check balance:

answer

Romber test

question

Screenings are being held for scoliosis . A nurse is observing the student for the presence of :

answer

an S shaped curvature of the spine

question

a nurse notes that the patient has suspected pancreatitis . The nurses assesses the patient for:

answer

positive rebound tenderness

question

An 80 yr old women is being assessed by a nurse on the gentitalia area and suspects that there may be a malignancy present due to the findings of:

answer

scaly, nodular lesions

question

A screening for osteoporosis is being conducted at an annual health fair. To determine the risk factors for osteoporosis a nurse is assessing for:

answer

a history of dieting and or alcohol abuse

question

patient has expressive aphasia, the nurse anticipates that this patient will:

answer

be unable to speak or write

question

To asses a patients visual fields , a nurse should :

answer

move a finger at arms length toward the patient form an angle

question

light palpation involves depressing the part being examined :

answer

1/2 inch

question

patients skin has vesicles present. Nurse finding of ;

answer

circumscribed elevations of skin filled with serious fluid

question

A nurse is assessing a patients level of consciousness using the Glasgow Coma Scale. The following findings are documented: Eyes open to speech, responses are oriented , localized pain is noted. The score for this patient :

answer

13

question

to assess the temperature of the patients skin, the nurse should use the :

answer

dorsal surface of the hand

question

The patient needs to sit upright to breath easier . This is recorded by the nurse as :

answer

orthopnea

question

orthopnea:

answer

shortness of breath when lying flat

question

the nurse observes a patient walk to the treatment room, turn, and step up to sit on the exam table. This is a way to obtain data related to which areas of the general survey?:

answer

-body type -hygiene and grooming -signs of physical distress -body movement and gait

question

A nurse assess the abdomen for bowel sounds. The nurse would listen to sounds with the patient in which position:

answer

supine with knees slightly flexed

question

which position should the nurse instruct the women to use to allow the best palpation of breast tissue ?:

answer

lying supine with a small folded towel under the shoulder, arm flexed behind the head

question

Child with asthma is having respiratory distress. The nurse aucultates high pitched, continuos musical sounds bilaterally over the lung fields. How should the sounds be documented :

answer

wheezes

question

a patient sustained a head injury after falling on the sidewalk. Which assessmens would indicate a change in neurological function ?:

answer

visual changes

question

7 rights:

answer

-right patient -right drug -right dose -right time -right route -right documentation -right to refuse

question

baseline assessment findings reflect a patients functional abilities and serve as the basis for :

answer

comparison with subsequent assessment findings

question

physical assessment of a child or infant requires the application of the principles of :

answer

growth and development

question

if you suspect substance abuse, conduct a :

answer

Quick Screen to determine the patients need for further intervention

question

a comprehensive physical assessment involves the use of five skills:

answer

inspection, palpation, percussion, auscultation, olfaction

question

inspection

answer

use of vision to assess distinguish normal from abnormal findings

question

palpation :

answer

involves the use of hands to touch body parts and make sensitive assessments. typically occurs right after inspection

question

percussion :

answer

involved tapping the body with the fingertips to produce a vibration that travels through body tissues

question

Auscultations:

answer

is listening for sounds produced by the body .

question

adventitious sounds

answer

abnormal lung sounds heard with auscultation

question

arcus senilis

answer

opaque ring, gray to white in color, that surrounds the periphery of the cornea. The condition is caused by deposits of fat granules in the cornea. Occurs primarily in older adults

question

cerumen

answer

yellowish or brownish waxy secretion produced by sweat glands in the external ear

question

costovertebral angle

answer

formed by the last rib and vertbral column is a landmark used during palpation of the kidney

question

crackles

answer

fine bubbling sounds heard on auscultation of the lungs: produced by air entering distal airways and alveoli, which contain serous secretions

question

dorsum

answer

back of the hand

question

indurated

answer

hardened

question

integument

answer

consists of the skin, hair, scalp and nails

question

orthopnea

answer

abnormal condition in which a person must sit or stand up to breath comfortably

question

pallor

answer

unnatural paleness of absence of color in the skin

question

phlebitis

answer

inflammation of the vein

question

thrill

answer

continuous palpable sensation like the purring of a cat

question

turgor

answer

normal resisliency of the skin caused by the outward pressure of the cells and interstitial fluids

question

best sight to inspect for jaundice :

answer

sclera

question

vitiligo

answer

loss of pigmentation

question

causes of clubbing

answer

180 degrees chronic lack of oxygen , heart or pulmonary disease

question

trichinosis

answer

a disease that people can get often by eating raw or undercooked meats that animals are infected w

question

strabismus

answer

crossed eyes

question

ptosis

answer

abrnormal drooping of the lid caused by edema or impairment of the third cranial nerve

question

acrus senilis

answer

thin white ring along the margin of the iris (common with aging but abnormal in anyone under the age of 40)

question

continous dilation of pupils results from

answer

neurological disorders, glaucoma, trauma, eye medication, withdrawal from opioids

question

tinitus

answer

ringing in the ear

question

vertigo

answer

loss of balance

question

otoscope

answer

used to observe the deeper structures of the external and middle ear

question

epistaxis

answer

nosebleeds

question

spongy gums usually indicate :

answer

periodontal disease or vit c deficiency

question

hemophilia

answer

group of hereditary genetic disorders that impairs the bodes ability to control blood clotting

question

areas drained by the head and neck are :

answer

mouth, throat, abdomen, breasts, thorax, arms

ch 16 health assessment and physical examination – Flashcards

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