physical assessment
Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply. Slowed movement Cartilage degeneration Increased bone density Increased range of motion Increased bone prominence
slowed movement, cartilage degeneration, increased bone prominence
A nurse is assessing an older adult male client. Which clinical findings are expected responses to the aging process? Slowed neurologic responses Lowered intelligence quotient Long-term memory impairment Forgetfulness about recent events Reduced ability to maintain an erection
slowed neurological responses, forgetfulness about recent events, reduced ability to maintain an erection
Which diagnostic study is used to determine a client's bone density?
standard X-ray
A nurse who is assessing a full-term newborn elicits the Moro reflex. Which method would the nurse utilize to best elicit this reflex? Touching the infant's cheek Striking the surface of the infant's crib suddenly Allowing the infant's feet to touch the surface of the crib Stroking the sole of the foot along the outer edge from the heel to the toe
striking the surface of the infant's crib suddenly
is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses
supine
Heart rate of above 100 bpm
tachycardia
Respiratory rate above 20
tachypnea
A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. Which assessment is the priority?
take the patients pedal pulse
what are some limits for patients to not be able to sit?
weak, unable to sit
High-velocity airflow through severely narrowed or obstructed airways results in a ______________ sound heard all over the lungs
wheezing
jaundice
yellowing of the skin
described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.
crackles
areas greater than 6 mm
diameter
A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? Report of pain when taking deep breaths Client is observed splinting the fracture site Diminished breath sounds on the affected side Bowel sounds are auscultated in the lower chest
diminished breath sounds on the affected side
What body position is where the patient lies on their back with the knees bent
dorsal recumbent
shortness of breath
dyspnea
what are some limitations/ considerations of the knee chest position
embarrassing/ uncomfortable (AWK)
turning the ankle inward toward the midline of the body
eversion
A nurse is demonstrating to a client how to manipulate the ankles through full range of motion. Which movements should the nurse use during this process?
eversion, inversion, dorsiflexion, plantar flexion
high pitched fine, short, interrupted crackling sounds heard during end of inspiration, usually not cleared by cough
fine crackles
Coughing up blood from the respiratory tract
hemoptysis
what are some limitations of the supine position?
if patient becomes short of breath raise the head of the bed!
A nurse performing a newborn assessment elicits the Babinski reflex. What does the nurse conclude that this finding indicates?
immaturity of the central nervous system
How do you prepare for a physical exam
infection control, environment, equipment, physical preparation, psychological
what order does an abdominal exam go in
inspection, auscultation, percussion, palpation
what order does an exam go in
inspection, palpation, percussion, auscultation
is turning the ankle outward away from the midline of the body.
inversion
what are some limitations of the sims position
joint difformities hinder patients ability to bend hips and knees
The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? Assess the client's lungs. Assess the client for pain. Obtain details of smoking habits. Ask about the onset of breathlessness.
assess the lungs
uneven shape
asymmetry
What things do you look for in skin lesions
asymmetry, border irregularity, color, diameter
cyanosis
bluish discoloration of the skin
edges blurred, notched, ragged
border irregularity
Heart rate less than 60 bpm
bradycardia
Respiratory rate less than 12
bradypnea
While assessing a client with a musculoskeletal disorder, the nurse gives the client a muscle strength rating of 3. What observation would correspond to this rating?
can complete ROM against gravity
The nurse recognizes that which are important components of a neurovascular assessment? Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation
capillary refill, pulse and skin temp, movement and sensation
occurs when there is decreased blood flow or injury to the brain stem that affects breathing
cheyne stokes
rate of depth are irregular alternating periods of apnea and hyperventilation
cheyne-stokes
Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences?
chinese americans
loud, bubbly sounds heard during inspirations, not cleared with coughing
coarse crackles
Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucous is present in the larger airways
coarse rhonci
what body position has patients knees on the bed (back and stomach are not touching bed)
knee chest
While assessing a client's musculoskeletal system, the nurse identifies genu valgum. Which joint might have been palpated by the nurse?
knee joint
is indicated for rectal assessment
knee-chest
hunchback
kyphosis
Why do nails club?
lack of oxygen, heart or pulmonary disease
what body position has patients laying on side with legs bent
lateral recumbent
What body position is supine?
laying down
What body position is laying on back, feet up in stirrups, knees bent
lithotomy
increased lumbar curvature
lordosis
lower, moister sounds heard during middle of inspiration, not cleared with coughing
medium crackle
what are some limitations/ considerations of the lithotomy position?
minimize time patient spends in position (AWKWARD)
A nurse is auscultating a client's heart sounds and hears S 1. Which valves is the nurse assessing? Mitral and tricuspid Aortic and tricuspid Mitral and pulmonic Aortic and pulmonic
mitral and tricuspid
When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. Which type of lung sounds will the nurse hear? Snorting sounds during the inspiratory phase Moist rumbling sounds that clear after coughing Musical sounds more pronounced during expiration Crackling inspiratory sounds unchanged with coughing
moist rumbling sounds that clear after coughing
What site do you hear the crackling of the lungs
most common in dependent lobes
After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this assessment?
motor function
What is the cause of Rhonci sounds in the lungs
muscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulence
A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority? warmth numbness peeling of the skin discomfort
numbness
person must sit or stand to breathe comfortably
orthopnea
pallor
paleness
What are some limitations that follow dorsal recumbent
patients with painful disorders
what are some limitations of lateral recumbent
patients with respiratory difficulties
what are some limitations of the prone position
patients with respiratory difficulties
when you touch the skin and it indents put does not rise back
pitting edema
Which action performed by the nursing student during the chest examination of a client needs correction? Placing the stethoscope over bony prominences Palpating two ribs inferiorly in the midaxillary line Dividing the anterior and posterior lungs into thirds Listening to at least one cycle of inspiration and expiration
placing the stethoscope over bony prominences
are of a dry or grating quality that is heard in the lower portion of the anterior lateral lung, as observed in client
pluera rub
Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties?
prone
is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well
prone
what body position is on stomach and arms folded above head
prone
what does PERRLA stand for
pupils equal, round, reactive to light and accommodation
what is the cause of crackling in the lungs?
random, sudden reinflation of groups of the alveoli, disruptive passage of air through small airways
erythema
redness of the skin
patients should hear air conducted sound twice as long as bone
rhine test
Loud, low pitched, rumbling, coarse sounds are heard either during inspiration or expiration; sometimes cleared by coughing
rhonchi
particularly on expiration, indicate partial airway obstruction because of bronchiolar alterations associated with COPD and usually clear with coughing. Snorting sounds are made in the nose. Wheezes are musical sounds usually heard during expiration; they are caused by rapid vibration of bronchial walls. Crackling sounds heard on inspiration that are unchanged by coughing are known as fine crackles; they result when air passes through alveoli that partially are filled with fluid.
coarse rhonci
pigmentation not uniform
color
Primarily head over trachae and bronchi if loud enough able to be heard over most lung feilds
rhonchi
While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as?
contracture
lateral S-shaped curvature of the thoracic and lumbar spine
scoliosis
lateral spinal curvature
scoliosis
What is the body position on stomach with one leg bent up?
sims
A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? Vesicular Bronchial Crackles Rhonchi
crackles
is indicated to assess the rectum and vagina.
sims
irregular heart beat
arrhythmia
pitting edema +1
2 mm
+2
4mm
3+
6 mm
4+
8 mm
what parts of the heart produce the S2 sounds
The aortic and pulmonic
During auscultation of the heart, where does the nurse expect the first heart sound (S 1) to be the loudest?
apex of the heart
without breathing
apnea