chp.30 – Flashcard

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
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