Assessment ~ Exam 3

A, B, C

Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination? (Select all that apply) A) Masses B) Crepitus C) Tenderness D) Deep tendon reflexes E) Postural abnormalities

1

lub-dub is ______ heart beat

short term orientation

person, place, time, situation, or event

palpations

pounding, racing heartbeat

important for assessment of adolescent

take history in private involve with decision making use opportunities for health teaching

percussion

tapping a particular body part

hand grips / feet push/pulls

test equality and strength of musculoskeletal and neurological systems

palpation

touch and pressure, light and deep

false

true or false: it is okay to listen through patient's clothing

important for assessment of child

use correct size of equipment safety play bed vs. exam room

order of assessment (not abdomen)

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

left lung

2 lobes

A, B, C, D

During the breast and genital examination, which findings would the nurse document and report to the health care provider? (Select all that apply) A) Lesions on the genitalia B) Presence of hemorrhoids C) Unusual odor or discharge D) Excoriation of the breast tissue E) Symmetry of the breast tissue

B, C, E

On which elements should the nurse focus when performing the physical examination component of the functional assessment? (select all that apply) A) Determining caregiver's abilities B) Evaluating coordination and gait C) Assessing for dyspnea with exertion D) Asking about use of a cane or walker E) Measuring blood pressure while the patient is seated and standing

SCRIPT

Site, Character, Radiation, Intensity, Pitch, Timing

LOC

level of consciousness

order of assessment of abdomen

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

Pulmonic valve location

2nd left intercostal space

Aortic valve location

2nd right intercostal space

right lung

3 lobes

systolic murmur

between S1 and S2

diastolic murmur

between S2 and S1

dyspnea

difficult or labored breathing

neck

do not palpate both sides of the ___________ at the same time

S4

extra heart sound - atrial filling, atrial gallop; a stiff wall "Tennessee"

S3

extra heart sound - may indicate heart failure; slushing in "Kentucky"

possible abnormal emotional data

flat affect, no eye contact

anterior thorax

front of the chest

bronchial breath sounds

harsh and loud

Apical pulse location

mitral valve

Asthma

wheezing progressing to absence of breath sounds

True

True or False: Comfort / Pain is the 6th assessment of vital signs

C

Observing the patient's gait and testing balance are included in which element of the adult head-to-toe examination with patient standing? A) Spinal B) Abdominal C) Neurologic D) Musculoskeletal

increase

pulse may ___________ with respiration

PERRLA

pupils are equal, round, and reactive to light and accommodation

inspection

purposeful observation

possible abnormal socialization

sits alone, no cards or visitors

possible normal emotional data

smiles, make eye contact

murmurs

sounds created by abnormal, turbulent flow of blood in the heart

expectoration

sputum expelled through mouth

Physical Assessment

systematic examination of body structures

B

Which nerve does the nurse examine by evaluating eye movements and pupillary reflexes? A) Motor nerve B) Cranial nerve C) Sensory nerve D) Accessory nerve

B

Which part of the eye would the nurse palpate gently to assess for nodules or pain? A) Lens B) Eyelid C) Cornea D) Orbital bone

C

Which part of the nose would the nurse palpate to assess for swelling, drainage, and tenderness? A) Nostrils B) Mucosa C) Sinuses D) Septum

A, B, D

Which physical assessment findings related to the musculoskeletal system would the nurse report to the health care provider? (Select all that apply) A) Pain B) Lesions C) Absence of crepitus D) Abnormal posture or gait E) Presence of deep tendon reflexes

C

Which technique would the nurse use to palpate the breast tissue? A) Both hands B) Palm of one hand C) Two to three fingers D) Thumb and forefinger

A, B, E

Which techniques would the nurse utilize to auscultate the patient's chest during the respiratory assessment? (Select all that apply) A) Listen for a full respiratory cycle. B) Use a systematic pattern. C) Assess at least two lobes. D) Feel for depth of breathing. E) Listen for unexpected sounds.

pneumothorax

absent sounds; collapsed lung

important for assessment of elderly

allow time for history safety with exam table recognize limitations assess activities of daily living consider caregiver needs may need several sessions

apical pulse

also called point of maximal impulse (PMI) or apex

posterior thorax

back of chest

possible normal socialization

converses with others, family present, etc.

1 full minute

count the apical rate for:

pneumonia

crackles and wheezes

pulmonary edema and heart failure

crackles early, wheezing late, does not clear with cough

atelectasis

crackles on inspiration- clear with cough

Clicks

heard with heart valve replacement

cardiac assessment techniques

inspection, palpation, auscultation

tricuspid valve location

left 4th intercostal space, sternal border

Where is the apical pulse located?

left 5th intercostal space, midclavicular line

mitral (apical) valve location

left midclavicular line, 5th intercostal space

Auscultation

listening to sounds, often with a stethoscope

pain assessment factors

location, frequency, quality, aggravating and relieving factors

mucus

material that coats many epithelial surfaces and is secreted into fluids (saliva)

sputum

matter that is expectorated from respiratory tract; describe the amount, color, viscosity, consistency, odor, etc.

bronchovesicular breath sounds

medium-pitched blowing sounds heard over the major bronchi

Musculoskeletal

muscles, bones, and joints

jugular vein distention (JVD)

observe for distention and level of pulsations with head of bed elevated; may indicate heart failure

cardiac assessment: inspection

observe for pulsations, heave or lift

posterior thorax excursion

observe symmetry of thorax and movement of air

long-term orientation

past events

vesicular breath sounds

peripheral; softer

B

Palpation of the thyroid and cervical lymph nodes is included in examination of which part of the body? A) Eyes B) Neck C) Mouth D) Pharynx

lub

S1, closing of atrioventricular valve; mitral, tricuspid close, loudest at apex

B

Which examination component should be performed while the adult patient is supine with the legs exposed? A) Palpation of breast tissue B) Palpation of popliteal pulse C) Palpation for inguinal hernia D) Palpation for aortic pulsation

A, B, C, E

Which findings would the nurse recognize as abnormal during assessment of the male genitalia? (Select all that apply) A) Rashes B) Lesions C) Masses D) Dimpling E) Discharge

A, B, C

In which order would the nurse perform an assessment of the integumentary system. A) Review the patient's medical records for preexisting issues with skin, hair, or nails. B) Interview the patient to complete the general survey, health history, and review of systems. C) Complete physical examination of the skin, hair, and nails.

D, B, A, C

Place the examination components in order for the adult patient who is supine. (select all that apply) A) Percuss liver border B) Inspect abdomen C) Palpate for pedal edema D) Auscultate heart

C

Which nerve does the nurse assess when applying dull and sharp stimuli to different areas of the body? A) Motor nerve B) Cranial nerve C) Sensory nerve D) Accessory nerve

dub

S2, aortic, pulmonic valves close, loudest at the second intercostal spaces

A, B

The abdominal and gastrointestinal organs are assessed during the evaluation of which body systems? (Select all that apply) A) Urinary B) Digestive C) Endocrine D) Circulatory E) Reproductive

A

The assessment of financial resources and health insurance is included in which element of the functional examination? A) Social situation B) Review of systems C) Physical examination. D) Activities of daily living

D

The healthcare provider palpates the prostate gland and seminal vesicles with the patient standing as part of which element of the examination? A) Spinal B) Rectal C) Neurologic D) Abdominal/Genital

A, B, C, E

When examining the head and its associated structures, which unexpected findings would the nurse document? (Select all that apply) A) Lumps B) Edema C) Lesions D) Symmetry E) Discoloration

A

When the nurse identifies clubbing of a patient's nails, which type of medical condition would the nurse suspect as the cause? A) Cardiac B) Neurologic C) Gastrointestinal D) Musculoskeletal

A

Which action allows the nurse to focus questions about the musculoskeletal system during the health history interview? A) Review of health records B) Organization of equipment C) Analysis of the review of systems D) Completion of the physical examination

C, E

Which actions would the nurse implement during auscultation of the cardiovascular system? (Select all that apply) A) Listen at all three valves B) Evaluate for symmetry C) Assess rate and rhythm D) Feel for quality of pulses E) Use both sides of stethoscope

A

Which additional body system would the nurse evaluate when assessing the cardiovascular and peripheral vascular systems? A) Respiratory B) Genitourinary C) Gastrointestinal D) Musculoskeletal

C

Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities? A) Apical pulse B) Peripheral pulses C) Peripheral perfusion D) Heart rhythm

B, C

Which aspects does the nurse assess while palpating the chest during the respiratory system assessment? (Select all that apply) A) Respiratory rate B) Masses C) Skin moisture D) Front-to-back diameter E) Breathing effort

A

Which assessment technique would the nurse use during the neurologic assessment? A) Inspection B) Reflexology C) Percussion D) Auscultation

A, B, E

Which assessment techniques would the nurse use during the abdominal assessment? (Select all that apply) A) Palpation B) Inspection C) Percussion D) Observation E) Auscultation

D

Which characteristic is the nurse assessing when placing thumbs on either side of the spine during the respiratory system assessment? A) Lung capacity B) Lung shape C) Respiratory rate D) Depth of respirations

C

Which component of the gastrointestinal assessment does the nurse evaluate using the diaphragm of the stethoscope? A) Wheezes B) Blood flow C) Bowel sounds D) Breath sounds

B, C, E

Which components would the nurse assess during palpation of the skin? (Select all that apply) A) Clubbing B) Swelling C) Skin texture D) Discoloration E) Skin temperature

D

Which element is performed after inspection and palpation of the patient's spine while the patient is standing? A) Test abdominal reflexes B) Palpate axillary lymph nodes C) Assess radial and brachial pulses D) Observe the patient walk heel to toe

C

Which element of the assessment should be performed after assessment of the patient's back, posterior chest, and lungs? A) Inspection of spine and scapula B) Palpation of posterior chest C) Palpation of apical pulse D) Weber test

B

Which element of the assessment should be performed with the patient seated and wearing a gown? A) Percussion of the posterior chest B) Inspection of facial symmetry C) Auscultation of heart and lungs D) Palpation of axillary lymph nodes

D

Which element of the functional assessment should be included during the review of systems? A) Blood pressure B) Ability to bathe C) Neurologic function D) Signs of dementia

C

Which elements should be performed after light palpation of all quadrants of the abdomen in the adult patient? A) Percussion of all quadrants B) Auscultation for bowel sounds C) Deep palpation of all quadrants D) Inspection of abdominal contour