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chp.30 – Flashcard

Ann Ricker

13 June 2020

question

What is a normal finding on auscultation of the lungs?

answer

resonance over the left upper lobe

question

the nurse positions the client sitting upright during palpation of?

answer

head and neck

question

after auscultating the abdomen, the nurse should report which finding to the primary care provider?

answer

bruit over the aorta

question

if unable to locate the client's popliteal pulse during a routine examination, what should the nurse perform next?

answer

check for a pedal pulse

question

what is an expected finding during assessment of the older adults?

answer

decreased peripheral, color, and night vision

question

what aspects of the skin does the nurse assess during a routine examination?

answer

color turgor temperature moisture lesions odor edema

question

if the client reports loss of short-term memory, the nurse would assess this by?

answer

asking the client to describe how he/she arrived at this location

question

to palpate lymph nodes, the nurse uses what technique?

answer

use of pads of two fingers in a circular motion

question

The nurse begins the physical examination with inspection. Which techniques would the nurse include in the inspection of the client?

answer

Viewing the interior of the ear with a scope Determining pupil reaction Noting green drainage from the left eye

question

The nurse is preparing to perform a physical assessment on the client's abdomen. In which order would the nurse perform the assessment?

answer

Inspection Auscultation Percussion Palpitation

question

The nurse is preparing to assess the client's liver size. Which examination technique is the most appropriate for the nurse to use?

answer

Percussion

question

The nurse explains to a new graduate that light palpation is used for certain examinations. Which statement by the new nurse indicates understanding of the teaching?

answer

"Light palpation is used to assess pulses."

question

The nurse auscultates the lungs of the client, who is suspected of having pneumonia, and hears rhonchi. Which assessment technique is best to use to determine if there is dullness in the lungs?

answer

Perform direct percussion.

question

Which action indicates a need for the further teaching of the nurse regarding percussion?

answer

Uses the pad of the striking finger when delivering the blow

question

The nurse is preparing to conduct a physical exam on a client who reports shortness of breath. What is the priority assessment technique for this client?

answer

Auscultating the lungs

question

The nurse is preparing to assess the client's abdomen. When would the nurse perform auscultation of the abdomen?

answer

Auscultation is performed before percussion and palpation.

question

The nurse is preparing to perform an assessment on a 32-year-old client. Which interventions would the nurse include in the inspection phase of the assessment?

answer

Ensure adequate exposure of body parts while maintaining privacy. Provide rationale for what is occurring to keep client informed. Ask the client's permission prior to starting the exam. Apply critical thinking skills to analyze data obtained.

question

The nurse is performing a newborn assessment of the musculoskeletal system. Which assessment technique is best used to assess for vibration and masses?

answer

Palpation

question

The nurse is preparing to palpate the client's abdomen. Which technique would the nurse use to best palpate organs of the abdomen?

answer

Dorsal surface of the hand

question

The nurse is assessing the client by placing only the hyperextended middle finger of the nondominant hand over the area being examined and uses only wrist action of the dominant hand to deliver two sharp blows using only the middle finger of the dominant hand. What is the best description of the assessment technique the nurse is using?

answer

Indirect percussion

question

The nurse is preparing to perform a physical assessment on a 33-year-old client. Which action by the nurse during percussion indicates a need for the nurse's further teaching regarding percussion?

answer

Uses direct percussion when assessing the client's gallbladder Uses indirect percussion when assessing for tenderness of the liver

question

The nurse is preparing to auscultate the client's lungs. Which technique used by the nurse indicates a need for the nurse's further teaching regarding auscultation?

answer

Places the stethoscope on the client's gown when listening to heart and lung sounds.

question

The nurse is teaching a new nurse about physical assessment while preparing to assess the abdomen of the client during an annual physical exam. Which statement about auscultation by the new nurse indicates understanding of the teaching?

answer

"I need to auscultate first because palpation and percussion can stimulate the bowel."

question

When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory phase of each respiratory cycle. These sounds are best identifies as?

answer

crackles

question

When performing a complete, head-to-toe physical examination, which physical-assessment technique should your perform first?

answer

inspection

question

what is exophthalmos and what causes it?

answer

a protusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression -caused by hyperthyroidism

question

what is jaundice and what causes it?

answer

a yellowish tinge, may first be evident in the sclera of the eyes and then in the mucous membranes and the skin -caused by liver disease

question

what respiratory assessment findings should be reported to the doctor immediately?

answer

crackles gurgles friction rub wheeze

question

what sites you assess heart sounds at?

answer

Aortic Area -2nd right intercostal space Pulmonary Area - 2nd left intercostal space Erb's Point- 3rd left intercostal space Tricuspid Area- 4th left intercostal space Apex - 5th left intercostal space (midclavicular line)

question

how to assess for JVD and if present what it indicates.

answer

indicate right-sided heart failure -the adequacy of function of the right side of the heart and venous pressure.

question

what part of the health assessment can be delegated to the UAP

answer

due to the substantial knowledge and skill required, assessments are not delegated to UAP

question

steps to an abdominal exam and in which order the assessment techniques are used

answer

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

question

_________is done before palpation and percussion in an abdominal exam because palpation & percussion cause movement or stimulation of the bowel, which can increase bowel motility and heighten bowel sounds, creating false results

answer

auscultation

question

the normal and abnormal findings that may be seen in a breast exam

answer

Normal: NO tenderness, masses, nodules, or nipple discharge Abnormal: Tenderness, masses, nodules, or nipple discharge

question

normal and abnormal findings in a peripheral pulses

answer

Normal Symmetric pulse volumes Full pulsations Abnormal Asymmetric volume Absence of pulsation Decreased, weak, thready pulsations Increased pulse volume

question

normal and abnormal findings in a peripheral viens

answer

Normal Symmetric in size Limbs not tender Abnormal Swelling of one calf or leg Tenderness on palpation

question

normal and abnormal findings in a peripheral percussions

answer

Normal Skin color pink Abnormal Cyanotic Pallor that increases with limb elevation Dependent rubor, a dusky red color

question

aphasia

answer

any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex

question

Sensory or receptive aphasia

answer

is the loss of the ability to comprehend written or spoken words

question

Auditory aphasia

answer

clients have lost the ability to understand the symbolic content associated with sounds

question

Visual aphasia

answer

clients have lost the ability to understand printed or written figures

question

Motor or expressive aphasia

answer

involves loss of the power to express oneself by writing, making signs, or speaking

question

what reflexes are and how are they assessed

answer

-is an automatic response of the body to a stimulus -It is not voluntarily learned or conscious -tested using a percussion hammer

question

what exam is used to detect cervical cancer

answer

Papanicolaou test (Pap test)

question

the four primary techniques used in the physical assessment

answer

Inspection- visual examination Palpation- examination of the body by touch Percussion- striking the body to elicit sounds that can be heard or vibrations that can be felt Auscultation- the process of listening to sounds produced with the body

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question

What is a normal finding on auscultation of the lungs?

answer

resonance over the left upper lobe

question

the nurse positions the client sitting upright during palpation of?

answer

head and neck

question

after auscultating the abdomen, the nurse should report which finding to the primary care provider?

answer

bruit over the aorta

question

if unable to locate the client's popliteal pulse during a routine examination, what should the nurse perform next?

answer

check for a pedal pulse

question

what is an expected finding during assessment of the older adults?

answer

decreased peripheral, color, and night vision

question

what aspects of the skin does the nurse assess during a routine examination?

answer

color turgor temperature moisture lesions odor edema

question

if the client reports loss of short-term memory, the nurse would assess this by?

answer

asking the client to describe how he/she arrived at this location

question

to palpate lymph nodes, the nurse uses what technique?

answer

use of pads of two fingers in a circular motion

question

The nurse begins the physical examination with inspection. Which techniques would the nurse include in the inspection of the client?

answer

Viewing the interior of the ear with a scope Determining pupil reaction Noting green drainage from the left eye

question

The nurse is preparing to perform a physical assessment on the client's abdomen. In which order would the nurse perform the assessment?

answer

Inspection Auscultation Percussion Palpitation

question

The nurse is preparing to assess the client's liver size. Which examination technique is the most appropriate for the nurse to use?

answer

Percussion

question

The nurse explains to a new graduate that light palpation is used for certain examinations. Which statement by the new nurse indicates understanding of the teaching?

answer

"Light palpation is used to assess pulses."

question

The nurse auscultates the lungs of the client, who is suspected of having pneumonia, and hears rhonchi. Which assessment technique is best to use to determine if there is dullness in the lungs?

answer

Perform direct percussion.

question

Which action indicates a need for the further teaching of the nurse regarding percussion?

answer

Uses the pad of the striking finger when delivering the blow

question

The nurse is preparing to conduct a physical exam on a client who reports shortness of breath. What is the priority assessment technique for this client?

answer

Auscultating the lungs

question

The nurse is preparing to assess the client's abdomen. When would the nurse perform auscultation of the abdomen?

answer

Auscultation is performed before percussion and palpation.

question

The nurse is preparing to perform an assessment on a 32-year-old client. Which interventions would the nurse include in the inspection phase of the assessment?

answer

question

The nurse is performing a newborn assessment of the musculoskeletal system. Which assessment technique is best used to assess for vibration and masses?

answer

Palpation

question

The nurse is preparing to palpate the client's abdomen. Which technique would the nurse use to best palpate organs of the abdomen?

answer

Dorsal surface of the hand

question

answer

Indirect percussion

question

The nurse is preparing to perform a physical assessment on a 33-year-old client. Which action by the nurse during percussion indicates a need for the nurse's further teaching regarding percussion?

answer

Uses direct percussion when assessing the client's gallbladder Uses indirect percussion when assessing for tenderness of the liver

question

The nurse is preparing to auscultate the client's lungs. Which technique used by the nurse indicates a need for the nurse's further teaching regarding auscultation?

answer

Places the stethoscope on the client's gown when listening to heart and lung sounds.

question

answer

"I need to auscultate first because palpation and percussion can stimulate the bowel."

question

When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory phase of each respiratory cycle. These sounds are best identifies as?

answer

crackles

question

When performing a complete, head-to-toe physical examination, which physical-assessment technique should your perform first?

answer

inspection

question

what is exophthalmos and what causes it?

answer

a protusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression -caused by hyperthyroidism

question

what is jaundice and what causes it?

answer

a yellowish tinge, may first be evident in the sclera of the eyes and then in the mucous membranes and the skin -caused by liver disease

question

what respiratory assessment findings should be reported to the doctor immediately?

answer

crackles gurgles friction rub wheeze

question

what sites you assess heart sounds at?

answer

question

how to assess for JVD and if present what it indicates.

answer

indicate right-sided heart failure -the adequacy of function of the right side of the heart and venous pressure.

question

what part of the health assessment can be delegated to the UAP

answer

due to the substantial knowledge and skill required, assessments are not delegated to UAP

question

steps to an abdominal exam and in which order the assessment techniques are used

answer

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

question

answer

auscultation

question

the normal and abnormal findings that may be seen in a breast exam

answer

Normal: NO tenderness, masses, nodules, or nipple discharge Abnormal: Tenderness, masses, nodules, or nipple discharge

question

normal and abnormal findings in a peripheral pulses

answer

Normal Symmetric pulse volumes Full pulsations Abnormal Asymmetric volume Absence of pulsation Decreased, weak, thready pulsations Increased pulse volume

question

normal and abnormal findings in a peripheral viens

answer

Normal Symmetric in size Limbs not tender Abnormal Swelling of one calf or leg Tenderness on palpation

question

normal and abnormal findings in a peripheral percussions

answer

Normal Skin color pink Abnormal Cyanotic Pallor that increases with limb elevation Dependent rubor, a dusky red color

question

aphasia

answer

any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex

question

Sensory or receptive aphasia

answer

is the loss of the ability to comprehend written or spoken words

question

Auditory aphasia

answer

clients have lost the ability to understand the symbolic content associated with sounds

question

Visual aphasia

answer

clients have lost the ability to understand printed or written figures

question

Motor or expressive aphasia

answer

involves loss of the power to express oneself by writing, making signs, or speaking

question

what reflexes are and how are they assessed

answer

-is an automatic response of the body to a stimulus -It is not voluntarily learned or conscious -tested using a percussion hammer

question

what exam is used to detect cervical cancer

answer

Papanicolaou test (Pap test)

question

the four primary techniques used in the physical assessment

answer

chp.30 – Flashcard

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