Kozier 30 - Physical Assessment

Cyanosis

A bluish tinge of skin color.

Mastoid

A bony prominence behind the ear.

Triangular Fossa

A depression in the antihelix.

Glaucoma

A disturbance in the circulation of the aqueous fluid that causes an increase in intraocular pressure.

Goniometer

A handheld device used to measure the angle of a joint in degrees.

Resonance

A hollow sound as produced by lungs filled with air during percussion.

Alopecia

A loss of scalp or body hair.

Tympany

A musical or drumlike sound produced during percussion over an air filled stomach.

Exophthalmos

A protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression. Overactivity of the thyroid gland

Erythema

A redness tinge of skin color associated with a variety of skin rashes.

Quality

A subjective description of an auscultated sound (e.g., whistling, gurgling, or snapping)

Resting Tremor

A tremor that is apparent when the client is at rest and diminishes with activity.

Thrill

A vibrating sensation over a blood vessel that indicates turbulent blood flow.

The best term for breath sounds created by air moving through large lung airways is a. Bronchovesicular. b. Rhonchi. c. Bronchial. d. Vesicular.

ANS: A Bronchovesicular breath sounds are created by air moving through large airways. Vesicular sounds are created by air moving through smaller airways. Bronchial sounds are created by air moving through the trachea close to the chest wall. Rhonchi are abnormal lung sounds that are loud, low-pitched, rumbling coarse sounds heard during inspiration or expiration that sometimes clear by coughing.

During a sexually transmitted illness presentation to high school students, the nurse recommends the HPV vaccine series to prevent a. Cervical cancer. b. Genital lesions. c. Vaginal discharge. d. Swollen perianal tissues.

ANS: A Human papillomavirus (HPV) infection increases the person's risk for cervical cancer. HPV vaccine is recommended by the American Cancer Society for females aged 9 to 26 years. Vaginal discharge, painful or swollen perianal tissues, and genital lesions are signs and symptoms that may indicate a sexually transmitted infection.

The patient is a 50-year-old African American male who has come in for his routine annual physical. Which of the following preventive screenings does the nurse recommend? a. Digital rectal examination of the prostate (DRE) annually b. Ca125 blood test once a year c. Complete eye examination every year d. Colonoscopy every 3 years

ANS: A Men need to have a digital rectal examination of the prostate every year beginning at 50 years of age. Ca125 blood tests are indicated for women at high risk for ovarian cancer. Because this patient is a man, Ca125 is not needed. Patients over the age of 65 need to have complete eye examinations yearly. Colonoscopy every 10 years is recommended in patients 50 years of age and older.

In preparation for a rectal examination of a nonambulatory male patient, the patient is informed of the need to be placed in which position? a. Sims' position b. Forward bending with flexed hips c. Knee-chest d. Dorsal recumbent

ANS: A Nonambulatory patients are best examined in a side-lying Sims' position. Forward bending would require the patient to be able to stand upright. Knees to chest would be difficult to maintain in a nonambulatory male and is embarrassing and uncomfortable. Dorsal recumbent does not provide adequate access for a rectal examination and is used for abdominal assessment because it promotes relaxation of abdominal muscles.

A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Considering the visual acuity results, the nurse informs the parent that the child a. Should have an optometric examination. b. Is suffering from strabismus. c. May have presbyopia. d. Has vision issues most likely due to cataracts.

ANS: A Normal vision is 20/20. The larger the denominator, the poorer the patient's visual acuity. For example, a value of 20/60 means that the patient, when standing 20 feet away, can read a line that a person with normal vision can read from 60 feet away. Strabismus is a (congenital) condition in which both eyes do not focus on an object simultaneously: These eyes appear crossed. Acuity may not be affected. Presbyopia is impaired near vision that occurs in middle-aged and older adults and is caused by loss of elasticity of the lens. Cataracts develop slowly and progressively after age 35 or suddenly after trauma.

An elderly patient has been on high doses of antibiotics and is experiencing a sudden loss of hearing. The nurse should contact the health care provider and a. Stop antibiotic use until the physician responds. b. Tell the patient that older patients often lose low-frequency hearing. c. Explain that hearing loss usually occurs with thinning of the eardrum. d. Assure the patient that rapid hearing loss is normal in the elderly.

ANS: A Older adults are especially at risk for hearing loss due to ototoxicity (injury to auditory nerve) resulting from high maintenance doses of antibiotics (e.g., aminoglycosides). Continuation of the medications is a physician responsibility. Older adults experience an inability to hear high-frequency sounds and consonants. Deterioration of the cochlea and thickening of the tympanic membrane cause older adults to gradually lose hearing acuity.

The patient has had a stroke that has affected her ability to speak, and she becomes extremely frustrated when she tries to speak. She responds correctly to questions and instructions but cannot form words coherently. This patient is showing signs of _____ aphasia. a. Expressive b. Receptive c. Sensory d. Combination

ANS: A The two types of aphasia are sensory (or receptive) and motor (or expressive). The patient cannot express herself in words and is showing signs of expressive aphasia. She responds correctly to questions and instructions, indicating that she does not have receptive or sensory aphasia. Patients sometimes suffer a combination of receptive and expressive aphasia, but this is not the case here.

On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. The nurse should evaluate the patient for a. Fluid retention. b. Fluid loss. c. Decreased nutritional reserves. d. Anorexia.

ANS: A This patient has gained 6 pounds in a 24-hour period. A weight gain of 5 pounds (2.3 kg) or more in a day indicates fluid retention problems. A downward trend may indicate a reduction in nutritional reserves that may be caused by decreased intake such as anorexia or by fluid loss.

A nurse suspects an abnormal thyroid shape during the physical examination. The nurse offers the patient a glass of water and observes her drinking to a. Visualize an enlarged thyroid gland. b. Evaluate for exostosis. c. Test the patient's gag reflex. d. Visualize the uvula and soft palate.

ANS: A This technique is used to visual an abnormally large thyroid gland. Normally, the thyroid cannot be visualized. An exostosis is a bony growth between the two palates that is noted when the oral cavity is examined. The patient's gag reflex is tested by placing a tongue depressor on the posterior tongue. The uvula and soft palate are visualized by using a penlight. Both structures should rise centrally as the patient says, "Ah."

The school nurse is assessing the tympanic membranes of a 3-year-old child. Which of the following demonstrates proper technique? a. Using an inverted otoscope grip while pulling the auricle downward b. Pulling the auricle upward and backward c. Holding the handle of the otoscope between the thumb and index finger while the child lies on the weight scale d. Using an inverted otoscope grip while pulling the auricle upward

ANS: A Using the inverted otoscope grip while pulling the auricle downward is a common approach with child examinations because it prevents accidental movement of the otoscope deeper into the ear canal, as could occur with an unexpected pediatric reaction to the ear examination. The other techniques could result in injury to the child's tympanic membrane.

A febrile preschool-aged child presents to the after-hours clinic. Varicella is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. The nurse documents the varicellar lesions as which type of skin lesion? a. Vesicle b. Wheal c. Papule d. Pustule

ANS: A Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1 cm. Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in size. They are common with bug bits and hives. Papules are palpable, circumscribed, solid elevations in the skin that are smaller than 1 cm. Pustules are elevations of skin similar to vesicles, but they are filled with pus.

A nurse is assessing a patient's hearing. Which of the following items does the nurse gather before conducting the assessment? (Select all that apply.) a. Tuning fork b. Ophthalmoscope c. Cotton-tipped applicator d. Current list of medications e. Snellen chart

ANS: A, D The nurse uses a tuning fork when conducting the Weber test to assess lateralization of sound and the Rinne test to assess air and bone conduction—two tests used to assess hearing. A current list of patient medications is needed to determine whether the patient is taking any medications, such as antibiotics, that could possibly cause ototoxicity. Cotton-tipped applicators are not used during an ear examination; instead they are sometimes used to assess the patient's ability to distinguish sharp from dull sensations. Ophthalmoscopes and Snellen charts are used during a visual examination.

During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. The nurse notifies the medical provider of the unexpected physical finding known as a. Clubbing. b. Bruit. c. Right-sided heart failure. d. Phlebitis.

ANS: B A bruit is the sound of turbulence of blood passing through a narrowed blood vessel. A bruit can reflect cardiovascular disease in the carotid artery of middle-aged to older adults'. Clubbing is due to insufficient oxygenation at the periphery resulting from conditions such as chronic emphysema and congenital heart disease; it is noted in the nails. Jugular venous distention, not bruit, is a possible sign of right-sided heart failure. Some patients with heart disease have distended jugular veins when sitting. Phlebitis is an inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, immobilization, and prolonged insertion of IV catheters. It affects predominantly peripheral veins

During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of a white, thick substance on the patient's uncircumcised glans penis. The nurse's next step is to a. Notify his provider about a suspected STI. b. Recognize this as a normal finding. c. Tell the patient to avoid doing self-examinations until symptoms clear. d. Avoid embarrassing questions about sexual activity.

ANS: B A small amount of thick, white smegma sometimes collects under the foreskin in the uncircumcised male. Penile pain or swelling, genital lesions, and urethral discharge are signs and symptoms that may indicate STI. All men 15 years and older need to perform a male-genital self-examination monthly. The nurse needs to assess a patient's sexual history and use of safe sex habits. Sexual history reveals risks for STI and HIV.

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. When performing an abdominal assessment, the nurse should a. Recommend that the patient take more laxatives. b. Ask the patient about the color of her stools. c. Avoid sexual references such as possible pregnancy. d. Assess first the spots that are most tender.

ANS: B Black or tarry stools (melena) indicate gastrointestinal alteration. The nurse should caution patients about the dangers of excessive use of laxatives or enemas. Determine if the patient is pregnant, and note her last menstrual period. Pregnancy causes changes in abdominal shape and contour. Assess painful areas last to minimize discomfort and anxiety.

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which of the following statements made by the new graduate nurse requires the preceptor to intervene? a. "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively." b. "Nursing assessment data are used only to provide information about the effectiveness of your medical care." c. "Nurses use data from their patient's physical assessment to determine a patient's educational needs." d. "Information gained from physical assessment helps nurses better understand their patients' emotional needs."

ANS: B Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care, not just the patient's medical care. Assessment data help to evaluate the effectiveness of medications and to determine a patient's health care needs, including the need for patient education. Nurses also use assessment data to identify patients' psychosocial and cultural needs.

During a preschool readiness examination, the nurse prepares to perform visual acuity screenings. Given the children's age, the best equipment to test central vision is which of the following? a. Snellen test b. E chart c. Reading test d. Penlight

ANS: B The E chart is used when an individual is unable to read, as would be the case for a preschool-aged child. A Snellen chart and a reading test are too advanced for a preschooler's education level. A penlight is used to check light perception. Shine a penlight into the eye, and then turn it off. If the patient notes when the light is turned on or off, light perception is intact.

An elderly patient is being seen for a chronic entropion. The nurse realizes that entropion places the patient at risk for which of the following? a. Ectropion b. Infection c. Exophthalmos d. Strabismus

ANS: B The diagnosis of entropion can lead to lashes of the lids irritating the conjunctiva and cornea. Irritation can lead to infection. Ectropion is when the eyelid margins turn out so that the lashes do not irritate the conjunctiva. Exophthalmos is a bulging of the eyes and usually indicates hyperthyroidism. Strabismus, or crossing of the eyes, results from neuromuscular injury or inherited abnormalities.

While assessing the skin of an 82-year-old male patient, a nurse discovers nonpainful ruby red papules on the patient's trunk. What is the nurse's next action? a. Explain that the patient has basal cell carcinoma and should watch for spread. b. Document cherry angiomas as a normal geriatric skin finding. c. Tell the patient that he has a benign squamous cell carcinoma. d. Document the presence of edema.

ANS: B The skin is normally free of lesions, except for common freckles or age-related changes such as skin tags, senile keratosis (thickening of skin), cherry angiomas (ruby red papules), and atrophic warts. Basal cell carcinoma is most common in sun-exposed areas and frequently occurs in a background of sun-damaged skin; it almost never spreads to other parts of the body. Squamous cell carcinoma is more serious than basal cell and develops on the outer layers of sun-exposed skin; these cells may travel to lymph nodes and throughout the body. Report abnormal lesions to the health care provider for further examination. Edema is an area of skin that becomes swollen or edematous from a buildup of fluid in the tissues. This has nothing to do with cherry angiomas.

A teen patient is tearful and reports locating lumps in her breasts. Other history obtained is that she is currently menstruating. Physical examination reveals soft and movable cysts in both breasts that are painful to palpation. The nurse also notes that the patient's nipples are erect, but the areolae are wrinkled. The next nursing step is which of the following? a. Reassure patient that her symptoms are normal. b. Consult a breast surgeon because of the abnormal nipples and areolae. c. Discuss fibrocystic disease as the likely cause. d. Tell the patient that the symptoms may get worse when her period ends.

ANS: C A common benign condition of the breast is benign (fibrocystic) breast disease. This patient has symptoms of fibrocystic disease, which include bilateral lumpy, painful breasts sometimes accompanied by nipple discharge. Symptoms are more apparent during the menstrual period. When palpated, the cysts (lumps) are soft, well differentiated, and movable. Deep cysts feel hard. Although a common condition, benign breast disease is not normal; therefore, the nurse does not tell the patient that this is a normal finding. During examination of the nipples and areolae, the nipple sometimes becomes erect with wrinkling of the areola. Therefore, consulting a breast surgeon to treat her nipples and areolae is not appropriate.

The patient is a 54-year-old male with a medium frame. He weighs 148 pounds and is 5 feet 8 inches tall. The nurse realizes that this patient is a. Overweight. b. Underweight. c. At his desired weight. d. Obese.

ANS: C According to the Metropolitan Life Insurance Company Statistical Bulletin, a male of medium frame who is 5 feet 8 inches tall should weigh between 145 and 157 pounds. This patient is at his desired weight. He is not overweight, underweight, or obese.

The paramedics transport an adult involved in a motor vehicle accident to the emergency department. On physical examination, the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. The nurse correctly identifies the patient's Glasgow Coma Scale score as a. 5. b. 7. c. 9. d. 11.

ANS: C According to the guidelines of the Glasgow Coma Scale, the patient has a score of 9. Opening eyes to pain is 2 points; inappropriate word use is 3 points; and flexion withdrawal is 4 points. The total for this patient is 2 + 3 + 4 = 9.

The advanced practice nurse is conducting a comprehensive eye examination on an 80-year-old African American woman. Which of the following findings requires the nurse to contact the patient's physician for further examination? a. A thin white ring along the margin of the iris b. A black pupil c. Dilated pupils d. A black fundus of the eye

ANS: C Dilated pupils result from glaucoma, trauma, neurological disorders, eye medication, or withdrawal from opioids. Shining a beam of light through the pupil and onto the retina stimulates the third cranial nerve and causes the muscles of the iris to constrict. Any abnormality along the nerve pathways from the retina to the iris alters the ability of the pupils to react to light. A thin white ring along the margin of the iris, called an arcus senilis, is common with aging but is abnormal in anyone younger than age 40. The pupils are normally black, round, regular, and equal in size. The fundus of African American patients can be black.

The nurse considers several new female patients to receive additional health education on the need for more frequent Pap smears and gynecological examinations. Which of the following assessment findings reveals the patient at highest risk for cervical cancer and thus having the greatest need for patient education? a. Nonsmoker, 13 years old, not sexually active b. Social smoker, 15 years old, celibate c. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners d. 50 years old, stopped smoking 30 years ago, history of hysterectomy

ANS: C Females considered to be at higher risk include those who smoke and are over 21 with weak immune systems, multiple sex partners, and a history of sexually transmitted infections. Of all the assessment findings listed, the 22-year-old smoker with multiple sexual partners has the greatest number of risk factors for cervical cancer. The other patients are at lower risk.

Asking an adult what the statement "A stitch in time saves nine" means to him is a mental status examination technique used to assess a. Knowledge. b. Long-term memory. c. Abstract thinking. d. Recent memory.

ANS: C For an individual to explain common phrases such as "A stitch in time saves nine" requires a higher level of intellectual function. Knowledge-based assessment is factual. Assess knowledge by asking how much the patient knows about his illness or the reason for seeking health care. To assess past memory, ask the patient to recall the maiden name of the patient's mother, a birthday, or a special date in history. It is best to ask open-ended questions rather than simple yes/no questions. Patients demonstrate immediate recall by repeating a series of numbers in the order in which they are presented or in reverse order.

The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. The proper sequence for the nurse's initial assessment is a. Deep palpation, light palpation, inspection. b. Light palpation, deep palpation, inspection. c. Inspection, light palpation. d. Auscultation, deep palpation, light palpation.

ANS: C Inspection is the use of vision and hearing to distinguish normal from abnormal findings. Light palpation determines areas of tenderness and skin temperature, moisture, and texture. Deep palpation is used to examine the condition of organs, such as those in the abdomen. Caution is the rule with deep palpation. Deep palpation is done after light palpation. Auscultation is used to evaluate sound.

A male student comes to the college health clinic. He hesitantly describes that his testis has lumps. The nurse recognizes this as a potential sign of which of the following? a. Inguinal hernia b. Sexually transmitted infection c. Testicular cancer d. Diuretic use

ANS: C Irregular lumps of the testes may indicate testicular cancer. Testicular cancer is cancer that begins in the testicles. Testicular cancer is the most common form of cancer in men between the ages of 15 and 35 years. A hernia presents with bulging in the scrotum. Sexually transmitted infections often present with genital lesions. Use of diuretics, sedatives, or antihypertensives can cause difficulty in achieving erection or ejaculation but does not usually cause lumps.

The nurse is caring for a female victim of rape. To perform the proper evaluation, the nurse should place the patient in which of the following positions? a. Sitting b. Dorsal recumbent c. Lithotomy d. Knee-chest

ANS: C Lithotomy is the position for examination of female genitalia. The lithotomy position provides for the maximum exposure of genitalia and allows the insertion of a vaginal speculum. Sitting does not allow adequate access for speculum insertion and is better used to visualize upper body parts. Dorsal recumbent is used to examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, and abdomen. Knee-chest provides maximal exposure of the rectal area but is embarrassing and uncomfortable.

During a school physical examination, the nurse reviews the patient's current medical history. With a positive medical history of asthma, eczema, and allergic rhinitis, the nurse expects which physical finding on nasal examination? a. Polyp b. Yellow discharge c. Pale nasal mucosa d. Puffiness of nasal mucosa

ANS: C Pale nasal mucosa with clear mucoid discharge indicates allergic rhinitis. Polyps are tumorlike growths. Yellow discharge would be seen with infection. Habitual use of intranasal cocaine and opioids causes puffiness and increased vascularity of the nasal mucosa

An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old American woman of Chinese descent. Which of the following nursing actions does the nurse do first? a. Place the patient in the lithotomy position. b. Drape the patient to enhance patient comfort. c. Assess the patient's feelings and explain the purpose of the examination. d. Ask the patient if she would like her mother to be present in the room during the examination.

ANS: C Patients who are Chinese American often believe that examination of the external genitalia is offensive. Before proceeding with the examination, the nurse first determines how the patient feels about the procedure and explains the procedure to answer any questions and to help the patient feel comfortable with the assessment. Once the patient is ready to have her external genitalia examined, the nurse places the patient in the lithotomy position and drapes the patient appropriately. Typically, nurses ask adolescents if they want a parent present during the examination. The patient in this question is 25 years old, so she is not an adolescent. Asking her if she would like her mother to be present is inappropriate.

A nurse identifies Pediculosis humananus capitis. Considering the possible complications of treatment, the nurse knows to not use which of the following treatment products? a. Fine-toothed comb b. Pediculicide c. Lindane-based shampoo d. Vinegar hair rinse

ANS: C Products containing lindane, a toxic ingredient, often cause adverse reactions. Instruct patients who have head lice to shampoo thoroughly with pediculicide (shampoo available at drugstores) in cold water, comb thoroughly with a fine-toothed comb, and discard the comb. A dilute solution of vinegar and water helps loosen nits.

Which is the best examination position for a complete geriatric physical examination on a weak patient with bilateral basilar pneumonia? a. Prone position b. Sims' position c. Supine position d. Lateral recumbent

ANS: C This is the most normally relaxed position. It will not compromise the patient's breathing because it is likely compromised with pneumonia. If the patient becomes short of breath easily, raise the head of the bed. This position would be easiest for an elderly weak person to get into position for an examination. Lateral recumbent and prone positions cause respiratory difficulty for any patient with respiratory difficulties. Sims' position is used for assessment of the rectum and the vagina.

A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Based on the physical findings, which of the following laboratory tests would the nurse expect to be ordered? a. Liver function test b. Lead level c. Thyroid-stimulating hormone test d. Complete blood count

ANS: C Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient who has jaundice. Lead levels and a CBC are not indicated for the presence of brittle hair.

Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters the patient's room and identifies himself, washes his hands with soap, and states the purpose of his visit. He performs proper identification of the patient before he auscultates her lungs. Which critical health assessment step was not performed? a. Running warm water over stethoscope for patient comfort b. Cleaning stethoscope with Betadine c. Using alcohol-based hand disinfectant d. Cleaning stethoscope with alcohol

ANS: D Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean is used. The stethoscope should be cleaned before use on each patient. Running water over the stethoscope does not kill bacteria. Betadine is an inappropriate cleaning solution and may damage the equipment. Hand sanitizer is not an approved cleaning product.

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Upon suspecting abuse, the school nurse's best next action is which of the following? a. Interviewing the patient in the presence of his/her teacher b. Ignoring the findings because child abuse is a declining problem c. Realizing that abuse victims usually report abusive situations d. Contacting Social Services and reporting suspected abuse

ANS: D Most states mandate a report to a social service center if nurses suspect abuse or neglect. When abuse is suspected, the nurse interviews the patient in private. Abuse of children, women, and older adults is a growing health problem. It is difficult to detect abuse because victims often will not complain or report that they are in an abusive situation.

During an annual gynecological examination, a college student discusses her upcoming college break at a tropical location. After the student receives an oral contraceptive prescription, the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic? a. Applying water-based sunscreen only before swimming b. Using tanning bed daily for 7 days before college break trip c. Applying broad-spectrum sunscreen of SPF 5 d. Taking extra precautions in the sun secondary to the prescription

ANS: D Oral contraceptives can make the skin more sensitive to the sun. For this reason, the patient should be educated about the need for sun protection such as wide-brimmed hats, use of broad-spectrum sunscreen of SPF 15 or greater, not tanning during midday, and not using tanning beds. Broad-spectrum sunscreens should be applied 15 minutes before going into the sun and after swimming or perspiring. Tanning parlors, sunlamps, etc., should be avoided. Sunscreens with SPF of 15 or greater should be used.

During a routine pediatric history and physical, the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born, and that he developed an infection that required "every antibiotic under the sun" to cure him. Considering the neonatal history, the nurse determines that it is especially important to perform a focused _____ examination. a. Cardiac b. Respiratory c. Ophthalmic d. Hearing acuity

ANS: D Risk factors for hearing problems include low birth weight, nonbacterial intrauterine infection, and excessively high bilirubin levels. Hearing loss due to ototoxicity (injury to auditory nerves) can result from high maintenance doses of antibiotics. Cardiac, respiratory, and eye examinations are important assessments but are not relevant to this child's condition.

A patient in the emergency department is complaining of left lower abdominal pain. The comprehensive abdominal examination would include, in proper order, which of the following? a. Inspection, palpation, auscultation b. Percussion, inspection, auscultation c. Inspection, palpation, percussion d. Inspection, auscultation, palpation

ANS: D The order of an abdominal examination differs slightly from that of other assessments. Begin with inspection and follow with auscultation. By using auscultation before palpation, the chance of altering the frequency and character of bowel sounds is lessened.

Objective physical data describe air moving through small airways over the lung's periphery. The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is which of the following? a. The inspiratory phase lasts exactly as long as the expiratory phase. b. The expiration phase is longer than the inspiration phase. c. The expiration phase is two times longer than the inspiration phase. d. The inspiratory phase is three times longer than the expiratory phase.

ANS: D Vesicular breath sounds are normal breath sounds; the inspiratory phase is three times longer than the expiratory phase. Bronchovesicular breath sounds have an inspiratory phase equal to the expiratory phase. Bronchial breath sounds have an expiration phase longer than the inspiration phase at a 3:2 ratio.

The patient presents to the clinic with dysuria and hematuria. How does the nurse proceed to assess for kidney inflammation? a. Lightly palpates each abdominal quadrant b. Inspects abdomen for abnormal movement or shadows using indirect lighting c. Uses deep palpation posteriorly d. Percusses posteriorly the costovertebral angle at the scapular line

ANS: D With the patient sitting or standing erect, use direct or indirect percussion to assess for kidney inflammation. With the ulnar surface of the partially closed fist, percuss posteriorly the costovertebral angle at the scapular line. If the kidneys are inflamed, the patient feels tenderness during percussion. Use a systematic palpation approach for each quadrant of the abdomen to assess for muscular resistance, distention, abdominal tenderness, and superficial organs or masses. Light palpation would not detect kidney tenderness because the kidneys sit deep within the abdominal cavity. Posteriorly, the lower ribs and heavy back muscles protect the kidneys, so they cannot be palpated. Kidney inflammation will not cause abdominal movement. However, to inspect the abdomen for abnormal movement or shadows, the nurse should stand on the patient's right side and inspect from above the abdomen using direct light over the abdomen.

Adventitious Breath Sounds

Abnormal breath sounds that occur when air passes through narrowed airways or airways filled with fluid or mucus, or when plural linings are inflamed.

Sordes

Accumulation of foul matter (food, microorganisms, and epithelial elements) on the teeth and gums.

Pyorrhea

Advanced periodontal disease in which the teeth are loose and ous is evident when the guns are pressed.

Intensity

Amplitude. The loudness or softness of auscultated sound.

Lift

An abnormal anterior movement of the chest related to enlargement of the right ventricle.

Fasciculation

An abnormal contraction of a bundle of muscle fibers that appears as a twitch.

Precordium

An area of the chest overlying the heart.

Reflex

An automatic response of the body to stimulus.

Flatness

An extremely dull sound produced during percussion by very dense tissue such as muscle or bone.

Tremor

An involuntarily trembling of a limb or body part.

Cataracts

An opacity of the eye lens or its capsule that blocks light rays.

Astigmatism

An uneven curvature of the cornea that prevents vertical and horizontal light rays from focusing on the retina.

Aphasia

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.

Obtunded

Aroused by shaking or shouting only by stimuli. returns to sleep

Miosis

Constricted pupils.

Vestibule

Contains the organs of equilibrium; found in the inner ear.

Strabismus

Cross-eye.

Periodontal Disease

Disorder of the supportive structures of the teeth.

comatose

Does not open eyes to painful stimuli. No verbal response.

Cerumen

Earwax

Mydriasis

Enlarged pupils.

Hyperopia

Farsightedness.

Auricle

Flap of the ear.

Diastole

In measuring blood pressure, the period during which the ventricles relax.

Pleximeter

In percussion, the middle finger of the dormant hand that is placed firmly on the clients skin.

Plexor

In percussion, the middle finger of the nondominant hand or a percussion hammer used to strike the pleximeter.

Semicircular Canals

In the inner ear; contain the organs of equilibrium.

Conjunctivitis

Inflammation of the bulbar and palpebral conjunctiva.

Dacryocystitis

Inflammation of the lacrimal sac.

Parotitis

Inflammation of the parotid salivary gland.

Glossitis

Inflammation of the tongue.

Presbyopia

Loss of elasticity of the lens and thus loss of ability to see close objects as a result of the aging process.

Myopia

Nearsightedness.

Normocephalic

Normal head size.

Pallor

Paleness.

Perfusion

Passage of blood constituents through the vessels of the circulatory system.

Vitiligo

Patches of hypopigmented skin, caused by the destruction of melanocytes in the area.

Nystagmus

Rapid involuntary rhythmic eye movement.

Proprioceptors

Sensory receptors that are sensitive to movement and position of the body.

Lethargic

Sleeps but arouses easily, appropiate or confused responses

Stapes

Stirrups bone of the middle ear.

Hordeolum

Sty. Redness, swelling or tenderness of the hair follicle and glands that empty at the edge of the eyelids.

Stereognosis

The ability to recognise objects by touching and manipulating them.

One-point Discrimination

The ability to sense whether one or two areas of the skin are being stimulated by pressure.

Two-point Discrimination

The ability to sense whether one or two areas of the skin are being stimulated by pressure.

Antihelix

The anterior curve of the auricle's upper aspect.

Visual Fields

The area and individual can see when looking straight ahead.

Tragus

The cartilaginous protrusion at the entrance of the ear canal.

Visual Acuity

The degree of detail the eye can discern in an image.

External Auditory Meatus

The entrance of the ear canal.

Palpation

The examination of the body using the sense of touch.

Extinction

The failure to perceive touch on one side of the body when two symmetric areas of the body are touch simultaneously.

Fremitus

The faintly perceptible vibration felt through the chest wall when the client speaks.

S1

The first heart sound; occurs when the atrioventricular valves (mitral and tricuspid) close.

Pitch

The frequency (number of the vibrations per second) heard during auscultation.

Manubrium

The handle-like superior part of the sternum that joins with the clavicles.

Angle of Louis

The junction between the body of the sternum and the manubrium; the starting point for locating the ribs anteriorly.

Eustachain Tube

The part of the middle ear that connects the middle ear to the nasopharynx; stabilizes air pressure between the external atmosphere and the middle ear.

Systole

The period during which the ventricles contract.

Helix

The posterior curve of the auricle's upper aspect.

Edema

The presence of excess interstitial fluid in the body that makes skin appear swollen, shiny, and taut, and tends to blanch color. Direct trauma and impairement of venous return are two common causes as well.

Auscultation

The process of loathing to sounds produced within the body, such as with the use of a stethoscope that amplifies sounds and conveys them to the nurse's ear.

Hernia

The protrusion of an organ or tissue through an opening such as the abdominal or inguinal muscles.

Sensorineural Hearing Loss

The result of damage to the inner ear, the auditory nerve, or the hearing center of the brain.

S2

The second heart sound; occurs when the semilunar valves (aortic and pulmonic) close.

Caries

Tooth cavities.

PERRLA

Used to record normal assessment of the pupils; pupils equally round and react to light and accommodation.

A nurse is assessing a patient's hearing. Which of the following items does the nurse gather before conducting the assessment? (Select all that apply.) a. Tuning fork b. Ophthalmoscope c. Cotton-tipped applicator d. Current list of medications e. Snellen chart

Using the inverted otoscope grip while pulling the auricle downward is a common approach with child examinations because it prevents accidental movement of the otoscope deeper into the ear canal, as could occur with an unexpected pediatric reaction to the ear examination. The other techniques could result in injury to the child's tympanic membrane. DIF: Apply REF: 513-514 OBJ: Demonstrate the techniques used with each physical assessment skill. TOP: Assessment MSC: Physiological Integrity

Stuporous

Vigorous and repeated stimuli. Opens eyes to painful stimuli. Confused inappropiate

Inspection

Visual examination, which is assessing by the sense of sight.