Physical Assessment
Terms
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- Which lung has 3 lobes?
- The right side
- What does the nurse use physical assessment for?
- To gather baseline data, supplment, confirm or refute data, confirm and identify nursing diagnoses,to evaluate the physiological outcomes of care.
- How do nurses demonstrate accountability for their nursing care?
- By evaluating the results of nursing interventions.
- What is inspection?
- the process of observation.
- What are you inspecting each area for?
- size, shape, color, symmetry,position and abnormalities.
- What aspect of the hand should you use to assess the skin temperature?
- Dorsum of hand/fingers.
- What is percussion used for?
- To determine location, size and density of underlying structures.
- What are the five sound produced by percssion?
- Tympany, resonance, hyperresonance, dullness, and flatness.
- What is auscultation?
- Listening to sounds produced by the body.
- Which part of the stethoscope is best for low-pitched sounds?
- The bell.
- What causes the first heart sound?
- closing of the mitral valve.
- Where is the first heart sound best heard at?
- At the fifth intercostal space along the midclavicular line.
- What are the 5 skills of conducting a physical assessment?
- Inspection, palpation, percussion, auscultation, and olfaction.
- What is vital for a successful examination?
- Client comfort.
- What position would you put you client in to aid in detecting heart murmers?
- Lateral recumbent.
- When does assessment begin?
- When the nurse first meets the client.
- What is the first part of the physical examination?
- Vital signs.
- a weight gain of five pounds a day is indicitive of what?
- fluid retention.
- What is included in the assessment of the integument?
- skin, hair scalp and nails.
- What can be revealed in your assessment of the skin?
- changes in oxygenation, circulation, nutrition, local tissue damage, and hydration.
- Who is most at risk for alterations in their skin?
- Neurologically impaired clients, chornically ill, orthopedic clients, clients with deminished metal status, poor tissue oxygenation, low cardiac output,or inadequate nutrition.
- What is cyanosis and where are the assessment locations?
- Bluish color of the skin. You would assess the nail beds, lips, mouth, skin.
- What is yellowing of the skin and what are some causes?
- Jaundice and it can be caused byliver disease, destruction of red blood cells.
- What can deminish skin turgor?
- Edema or dehydration
- Surcumscribed elevation of the skin that is filled with serous fluid.
- Vesicle
- What does the nurse inspect the nail bed for?
- Color, dleanlimess, and length, the thickness and shape of the nail plate, the texture of the nail,the angle between the nail and the nailbed.
- What causes clubbing of the fingernails?
- Chronic lack of oxygen: heart or pulmonary disease.
- What is nystagmus?
- involuntary ,rhythmical oscillation of the eyes.
- Bulging of both eyes can be caused by....
- hyperthyroidism.
- Tears are secreted from what gland?
- lacrimal
- PERRLA?
- PUPILS,EQUAL,ROUND, REACTIVE, AND ACCOMODATION
- Low set ears are a sign of which chromosome abnormality?
- Down Syndrome
- what is ototoxicity?
- Injury to auditory nerve resulting from high maintenance doses of antibiotics.
- What is tactile femitus?
- Vibrations that can be palpated externally during speech.
- What is the Allen's test used for?
- To assess collateral circulation.
- How do you assess capillary refill? What is an appropriate finding?
- Blanch nailbed for several seconds. Normal refill should be less than 2 seconds.
- How often should BSE be performed in women 20 yrs of age and older?
- Monthly.
- At what age should women have a routine mammogram?
- Age 40
- What organ can be palpated in the upper right quadrant?
- Liver.
- What is the first technique the nurse employes during a physical exam?
- Inspection.
- In what order is the abdomen assessed?
- Inspection, auscultation, then palpation.
- What pattern of comparison is used to auscultate the lungs?
- side to side.
- What is thermoregulation?
- The balance between heat lost and heat produced.
- THe transfer of heat from the surface of one object to the surface of another is called...
- Radiation.
- The transfer of heat from one object to antoher with direct contact....
- conduction
- the transfer of heat away by air movement.
- convection
- the transfer of heat enery when a liquid is changed to a gas...
- evaporation
- When is the body temp. usually lowest? highest?
- between 1 and 4 am. 6pm
- s/s of heatstroke.
- giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances and incontinence.