Nurs1500 LSN unit I

Health history components: Source of history

- client, family members or close friends, other medical records, other providers - reliability of the historian

Therapeutic communication for data collection

- introduce yourself and various parts of the assessment - determine what the client wants you to call him -allow more time for older adults -make sure the client is comfortable (room temperature,chair) - when possible, start by asking for the health history, perform general survey, and measure vital signs to build rapport prior to moving on to more sensitive parts of the exam - reduce environmental noises (tv, radio, visitors) to enhance communication and eliminate distractions - ensure understanding by obtaining interpretive services for language or other communication barriers -note nonverbal communication (body language, eye contact, tone) -avoid using medical jargon, giving advice, ignoring feelings, and offering false reassurance

Inspect, Palpate, Percuss, Auscultate (in this order) Inspection

-A penlight, an otoscope, an ophthalmoscope, or another lighted instrument can enhance the process -Inspection involves using the senses of vision, smell (olfaction), and hearing to observe and detect any expected or unexpected findings. Inspect for size, shape, color, symmetry (comparing both sides of the body), and position -Validate findings with the client

Expected changes with aging: Lungs

-Chest shape changes sot that the AP diameter becomes similar to the transverse diameter (barrel chest), resulting in decreased vital capacity. -Chest excursion or expansion diminishes -Cough reflex diminishes -Cilia ineffectively removes dust and irritants from the airways -Alveoli dwindle, airway resistance increases, and the risk of pulmonary infection increases -Kyphosis, an increased curvature of the thoracic spine due to osteoporosis and weakened cartilage, results in vertebral collapse and impairment of respiratory effort.

Inspect, Palpate, Percuss, Auscultate (in this order) Percussion

-Direct percussion, which involves striking the body to elicit sounds -Indirect percussion, which involves placing your hand flatly on the body, as the striking surface, for sound production -First percussion, which helps identify tenderness over the kidneys, liver, and gallbladder

Inspect, Palpate, Percuss, Auscultate (in this order) Auscultation

-Evaluate sounds for amplitude or intensity (loud or soft), pitch or frequency (high or low), duration (time the sound lasts), and quality (what it sounds like) -Use the diaphragm of the stethoscope to listen to high pitched sounds (heart sounds, bowel sounds, lung sounds) -----Place the diaphragm firmly on the body part -Use the bell of the stethoscope to listen to low pitched sounds (unexpected heart sounds, bruits) -----Place the bell lightly on the body part

Expected changes with aging

-Eyes: Decreased visual acuity, decreased peripheral vision, diminishing ability to see close objects or read small print (presbyopia), decreased ability to accommodate extreme changes in light (glare, darkness), difficulty distinguishing colors, intolerance to glare, delayed pupillary reaction to light, yellowing of the lens, thin gray white ring surrounding the cornea, loss of lateral third of eyebrows -Ears: Hearing loss, loss of acuity for high frequency tones (presbycusis), cerumen accumulation in the ear canal, thickening of the tympanic membrane -Mouth: Decreased sense of taste due to reduced number of taste buds, tooth loss, pale gums, gum disease due to inadequate oral hygiene, darkening of teeth, decreased salivation -Voice: Rise in pitch, loss of power and range -Nose: Decreased sense of smell

List the 13 common types of motion along with the actions that demonstrate them

-Flexion: A movement that decreases the angle between two adjacent bones -Extension: A movement that increases the angle between two adjacent bones -Hyperextension: Movement of a body part beyond its normal extended position -Supination: movement of a body part so the ventral or front surface faces up -Pronation: movement of a body part so the ventral surface or front surface faces down -Abduction: The movement of an extremity away from the midline of the body -Adduction: The movement of an extremity toward the midline of the body -Dorsiflexion: Flexing the foot and toes upward -Plantar flexion: bending the foot and toes downward -Eversion: turning the body part away from the midline -Inversion: turning the body part toward the midline -External rotation: Rotating a joint outward -Internal rotation: rotating a joint inward

Physical Assessment Techniques

-Make sure there is adequate lighting -Maintain a comfortable and quiet environment -Provide privacy, using a gown or draping the client with a sheet and visualizing only one section of the body at a time -Explain the various assessment/data collection techniques you will use -Look and observe before touching -Keep nails short, and hands and stethoscope warm -Do not feel or listen through clothing (clothing can obscure or create sounds) -Have necessary equipment ready -Use standard precautions when in contact with body fluids, wound drainage, and open lesions For older adults: -Allow enough time for position changes - Perform assessments/data collection in several shorter segments to avoid overtiring. Organize the examination, finishing all techniques requiring the same position before movine on to the next position -Make sure older adults who use sensory aids (glasses, hearing aids) have them available for use -Invite the client to use the bathroom before beginning the physical examination. Collect urine and fecal specimens at this time

List the nine chains of lymph nodes and the location of each, in appropriate sequence for palpating them

-Occipital nodes: base of the skull -Postauricular nodes: over the mastoid -Preauricular nodes: in front of the ear -Tonsillar (retropharyngeal) nodes: angle of the mandible -Submandibular nodes: along the base of the mandible -Submental nodes: midline under the chin -Anterior cervical nodes: along the sternocleidomastoid muscle -Posterior cervical nodes: posterior to the sternocleidomastoid muscle -Supraclavicular nodes: above the clavicles

Expected changes with aging: Integumentary system

-Skin thin and translucent, dry, flaky, tears easily, loss of elasticity, and wrinkling -Thinning of hair -Slow growth of nails with thickening -Decline in glandular structure and function (less oil, moisture,, sweat) -Uneven pigmentation -Slow wound healing -Little subcutaneous tissue over bony prominences Peripheral vascular system: -Thicker, more rigid peripheral blood vessel walls with a narrowed lumen leading to poor peripheral circulation -Higher systolic blood pressure

Expected changes with aging; Cardiovascular system

-Systolic hypertension (widened pulse pressure) is a common finding with atherosclerosis -The PMI becomes more difficult to palpate because the AP diameter of the chest widens -Coronary blood vessel walls thicken and become more rigid with a narrowed lumen -Cardiac output decreases and strength of contraction leads to poor activity tolerance -Heart values stiffen due to calcification - The left ventricle thickens -Pulmonary vascular tension increases - Systolic blood pressure rises -Peripheral circulation diminishes

Inspect, Palpate, Percuss, Auscultate (in this order) Palpation

-Use light palpation (less than 1cm) for most body surfaces. Use deeper palpation (4cm) to evaluate abdominal organs or masses -Various parts of your hands detect different sensations -----The dorsal surface is the most sensitive to temperature -----The palmar surface and base of the fingers are sensitive to vibration -----Fingertips are sensitive to pulsation, position, texture, turgor, size, and consistency -----The fingers and thumb are useful for grasping an organ or mass -Starting with light palpation, be systemic, calm, and gentle. Proceed to deep palpation if necessary

Expected changes with aging: Abdomen

-Weakened abdominal muscles declining in tone and more adipose tissue result in a rounder, more protruding abdomen -Peritoneal inflammation is more difficult to detect due to less pain, guarding, fever, and rebound tenderness -Saliva, gastric secretions, and pancreatic enzymes decrease - Esophageal peristalsis and small-intestine motility decrease

Expected changes with aging: Breasts

-With menopause, glandular tissue atrophies. Adipose tissue replaces it, making it feel softer and more pendulous. The atrophied ducts can feel like thin strands. -Nipples no longer have erectile ability and can invert

BP Classifications: Prehypertension

120-139 Systolic or 80-89 Diastolic

BP classifications: Stage 1 Hypertension

140-159 Systolic or 90-99 Diastolic

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

16/min

A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status

A.B.C. Posture. Skin lesions, Speech are the part of the body structure or general appearance portion fo the general survey

Health history components: Chief concern

A brief statement in the client's own words of why he is seeking care

A nurse auscultates the thorax and lungs and heard coarse, low pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. The nurse would document these sounds as: A. Adventitious breath sounds B. Bronchovesicular breath sounds C. Vesicular breath sounds D. Bronchial sounds

A. Adventitious breath sounds are sounds not normally heard in the lungs. Bronchovesicular breath sounds are normal sounds heard in inspiration and expiration. Vesicular breath sounds are soft, low pitched, whispering sounds; heard over most of the lungs fields. Bronchial sounds are blowing, hollow sounds, auscultated over the larynx and trachea

A nurse is assessing the bowel sounds of a patient who has Crohn's disease. What assessment technique would the nurse use? A. Auscultation B. Palpation C. Percussion D. Inspections

A. Auscultation

A nurse is instructing an assistive personal about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for the client? A. Do not measure the clients temperature rectally B. Count the client's radial pulse for 30 seconds and multiply it by 2 C. Do not let the client know you are counting her respirations D. Let the client rest for 5 minutes before you measure her blood pressure

A. Do not measure the client's temperature rectally. The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. The low platelet count contraindicates the use of the rectal route for this client

What assessment technique would the nurse use to assess a patient's chest for color, shape, or contour? A. Inspection B. Palpation C. Percussion D. Auscultation

A. Inspection

When inspecting the skin of a patient who has cirrhosis off the liver, the nurse notes that the skin has a yellow tint. What would the nurse document related to this finding? A. Jaundice B. Cyanosis C. Erythema D. Pallor

A. Jaundice is a yellowish skin color caused by liver disease. Cyanosis is a bluish skin color caused by a cold environment of decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury, trauma, or infection. Pallor is a paleness caused by anemia or shock .

The nurse is assessing the ear canal and tympanic membrane of a patient using an otoscope. Which finding would the nurse document as normal? A. The tympanic membrane is translucent, shiny, and gray. B. The ear canal is rough and pinkish C. The tympanic membrane is reddish D. The ear canal is smooth and white

A. The tympanic membrane is translucent, shiny, and gray

A nurse is palpating the breast of a woman during an assessment. Which technique is performed correctly? A. The nurse starts at the tail of Spence and moved in increasingly smaller circles B. The nurse uses the palm of the hands to gently compress the breast tissue against the chest wall. C. The nurse works in a counterclockwise direction and palpated from the periphery toward areola D. The nurse starts at the inner edge of the breast and palpated up and down the breast

A. When palpating the breast, the nurse would palpate each quadrant of each breast in a systematic method using either the circular, wedge, or vertical strip technique and then use the pads of the first three fingers to gently compress the breast tissue against the chest wall. In the circular method, the nurse would start at the tail of Spence and move in increasing smaller circles. In the Wedge method, the nurse would work in a clockwise direction and palpate from the periphery toward the areola. In the vertical strip method, the nurse would start at the outer edge of the breast and palpate up and down the breast.

A nurse is caring for a client who asks what their Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? A. Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet B. Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet C. Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet D. Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet

A. Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet. The first number is the distance (in feet) the client stands from the chart. The second number is the distance at which a visually unimpaired eye can see the same line clearly

A nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the client's balance? (Select all that apply0 A. Romberg test B. Heel to toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test

A.B. For the Romberg test, the client stands with his eyes closed, arms at his sides, and feet together. The nurse verifies balance if the client can stand with minimal swaying for at least 5 seconds. For the heel to toe walk, the client places the heel of one foot in front of the toes of the other foot as he walks in a straight line. The nurse verifies balance if the client can walk in a straight line without losing his balance

A nurse in the provider's office is preparing to auscultate and percuss a client's abdomen as a part of a comprehensive physical examination. Which of the following findings should the nurse inspect? (select all that apply) A. Tympany B. High pitched clicks C. Borborygmi D. Friction rubs E. Bruits

A.B. Tympany is expected drumlike percussion sound over the abdomen. It indicates air in the stomach. Typical bowel sounds are high pitched clicks and gurgles occurring about 35 times/min

A nurse is instructing a group of students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply) A. Place the client in Semi Fowler's position B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate D. Count the rate for 30 sec if it is irregular E. Count and report any sighs the client demonstrates

A.B.C. Place the client in Semi Fowlers position. Having the client sit upright facilitates full ventilation and gives the students a clear view of chest and abdominal movements Have the client rest an arm across the abdomen. With the client's arm across the abdomen or lower chest, it is easier for the students to see respiratory movements Observe one full respiratory cycle before counting the rate.. Observing one full cycle assists the students in obtaining an accurate count

A nurse is caring for an 82 year old client in the emergency department who has an oral body temperature fo 38.3 (101), pulse rate of 114/min, and respiratory rate of 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply) A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's fluid intake C. Encourage the client to rest and limit activity D. Allow the client to shiver to dispel excess heat E. Assist the client with oral hygiene frequently

A.C.E. Obtain culture specimens before initiating antimicrobials. The provider can prescribe cultures to identify any infectious organisms causing the fever. The nurse should obtain the culture specimens before the antimicrobial therapy to prevent interference with the detection of the infection. Encourage the client to rest and limit activity. Rest helps conserve energy and decreases metabolic rate. Activity can increase heat production Assist the client with oral hygiene frequently. Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips

A nurse caring for patients in a long term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask? Select all that apply A. Are you able to dress yourself? B. Do you have a history of smoking? C. What is the problem for which you are seeking care? D. Do you prepare your own meals? E. Do you manage your own finances? F. Whom do you rely on for support?

A.D.E. A functional health assessment focuses on the effects of health or illness on a patients quality of life, including the strengths of the patient and areas that need to improve. The nurse would assess the patients ability to perform ADLs and IADLs such as dressing, grooming, preparing meals, and managing finances. A history of smoking is can lifestyle factor and the chief complaint is the reason for seeking healthcare, both assessed during the health history. Social networks and support persons are assessed as psychosocial factors related to the health history.

A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on the inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding a symmetric extension off the trachea on both sides of the midline

A.D.E. Palpating the thyroid in the lower half of the neck. The thyroid gland lies in the anterior portion of the lower half of the neck, just in front of the trachea Feeling the thyroid ascend as the client swallows. When the client swallows a sip of water, the nurse should feel the thyroid move upward with the trachea Finding a symmetric extension off the trachea on both sides of the midline. The thyroid gland lies in front of the trachea and extends symmetrically to both sides of the midline

A nurse in a provider's office is preparing to performa breast examination for an older adult client who is postmenopausal. Which of the following finding should the nurse expect? (Select all that apply) A.Smaller nipples B. Less adipose tissue C. Nipple dishcharge D. More pendulous E.Nipple inversion

A.D.E. Smaller nipples; in older adulthood, the nipples become smaller and flatter. In older adulthood the breasts become softer and more pendulous. Nipple inversion is common among old adults, due to fibrotic changes and shrinkage

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following finding should the nurse expect? (Select all that apply) A. Capillary refill less than 2 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous light brown macules on the face

A.D.E. The nurse should expect capillary refill in less than 2 seconds as an expected finding The nurse should expect thicker skin on the palms of the hands and the soles of the client's feet The nurse should expect light brown macules on the face, such as freckles

BP Considerations:

Age: Infants have a low BP that gradually increases with age; Older children and adolescents have varying BP based on body size. Larger children have higher BP; Adults BP can increase with age; Older adult clients can have a slightly elevated systolic pressure due to decreased elasticity of blood vessels Circadian rhythms: affect BP, with BP usually lowest in the early morning hours and peaking during the later part of the afternoon or evening Stress: fear, emotional strain, and acute pain can increase BP Ethnicity: African Americans have higher incidence of hypertension in general and at earlier ages Sex: adolescent to middle age men have higher BP than their female counterparts. Postmenopausal women have higher BP than male counterparts Medications: Opiates, antihypertensives, and cardiac medications can lower BP. Cocaine, nicotine, cold medications, oral contraceptives, alcohol, and antidepressants can raise BP Exercise: decrease BP for several hours afterward Obesity: contributing factor to hypertension Family history: hypertension, lack of exercise, high sodium intake, and continuous stress can increase risk of hypertension

Respiration Considerations:

Age: Respiratory rate decreases with age. Newborns have rates of 35-40/min. School age children have respiratory rates of 20-30/min. Sex: Men and children are diaphragmatic breathers, and abdominal movements are more noticeable; women use more thoracic muscles and chest movements are more pronounced when they breath Pain: can decrease the number of respirations. At onset of acute pain, the RR increases but stabilizes over time Anxiety: increases the rate and depth of respirations Smoking: resting rate of respirations increase Body position: Upright positions allow the chest wall to expand more fully Medications: Opiods, Sedatives, bronchodiliaters, and general anesthesia decrease RR and depth. Respiratory depression is a serious adverse effect. Amphetamines and cocaine increase rate and depth Neurological injury to the brainstem decreases RR and rhythm Illnesses affect the shape of the chest wall, change the patency fo passages, impair muscle function, and diminish respiratory effort. With these conditions, use of accessory muscles, and the RR increase. Impaired oxygen-carrying capacity of the blood that occurs with anemia or at high altitudes results in increases in the RR and alteration in rhythm to compensate

Dysrhthmia

An irregular heart rhythm, generally an irregular radial pulse

A home health care nurse takes the vital signs of a patient who is receiving supplemental oxygen at home for chronic obstructive pulmonary disease (COPD). This is the nurse's fourth visit to the patients home. The nurse records the data collected in the patients chart. What type of assessment has this nurse performed? A. Comprehensive B. Ongoing partial assessment C. Focused assessment D. Emergency assessment

B. An ongoing partial assessment, or follow up assessment, is conducted at regular intervals (e.g. at the beginning of each home health visit or each hospital shift) during care of the patient. This type of assessment concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions. A comprehensive assessment with a health history and complete physical examination is usually conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessments. A focused assessment is conducted to assess a specific problem. An emergency assessment is a type of rapid focused assessment conducted when addressing a life threatening unstable situation.

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication B. Ask the client if she is having pain C. Request a prescription for an anti anxiety medication D. Return in 30 minutes fo recheck the client's blood pressure

B. Ask the client if she is in pain. The first action the nurse should take using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood pressure. Therefore, the nurses priority is to perform a pain assessment. If the client's blood pressure is still elevated after pain interventions, the nurse should report this finding to the provider

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema

B. Cyanosis. The priority finding when using the airway, breathing, circulation (ABC) approach to care is cyanosis, which is an indication of hypoxia (inadequate oxygenation). Therefore, the nurse should immediately report this finding to the provider.

During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate?(Select all that apply) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Closure of the tricuspid valve E.Murmur

B. D. To auscultate the closure of the mitral valve and tricuspid valve, the nurse places the diaphragm of the stethoscope over the apex, or the apical/mitral site, which is on the left midclavicular line at the fifth intercostal space

A nurse is assessing the lungs of a patient and auscultates soft, low pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? A. Suspect an inflamed pleura rubbing against the chest wall B. Document normal breath sounds C.Recommend testing for pneumonia D. Assess for asthma

B. Document normal breath sounds

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal? A. The patient's eyes do not converge when the nurse moves a finger toward his nose. B. The patient's pupils are black, equal in size, and round and smooth. C. An older adult's pupils are pale and cloudy D. The patient's pupils dilate when looking at a near object and constrict when looking at a distant object.

B. The patient's pupils are black, equal in size, and round and smooth

A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name. What level of consciousness would the nurse document? A. Awake and alert B. Lethargic C. Stuporous D. Comatose

B. The stages of consciousness are: Awake and alert: fully awake; oriented to person, place, and time; responds to all stimuli, including verbal commands. Lethargic: appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patients name Stuporous: unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements. Comatose: cannot next aroused, even with the use of painful stimuli; may have some reflex activity (such as gag reflex); if no reflexes present, is in deep coma

A nurse is assessing a patients eyes for extraocular movements. Which action correctly describes a step the nurse would take when performing this test? A. Ask the patient to sit about three feet away facing the nurse. B. Keep a penlight about 1 foot from the patients face and move it slowly through the cardinal positions. C. Move a penlight in a circular motion in front of the patients eyes. D. Ask the patient to cover one eye with a hand or index card

B. The testing for extraocular movements are; (1) ask the patient to sit or stand about 2 feet away, facing the nurse, who is sitting or standing at eye level with the patient; (2) asks the patient to hold the head still and follow the movement of a forefinger or penlight with the eyes; (3) keeping the finger or light about 1 foot from the patients face, move it slowly through the cardinal position- up and down, left and right, diagonally up and down to the right.

A nurse is using the FOUR Coma Scale to assess the neurologic status of a patient following surgery to remove a brain tumor. The nurses rates the patient as M2 for Motor response. What condition does this number represent? A. Localizing to pain B. Flexion response to pain C. Extension response to pain D. No response to pain

B. To assess motor response, patients are asked to make a peace sign, a fist, and snow thumbs up. Patients are scored as follows: M4 thumbs up, fist, or peace sign M3 localizing to pain M2 Flexion response to pain M1 Extension response to pain M0 No response to pain

A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? A. Olfaction B. Auscultation C.Palpation D.Percussion

B.Auscultation. Because palpation and percussion can alter the frequency and intensity of bowel sounds, the nurse should auscultate the abdomen next and before using those two techniques

Which actions would the nurse perform when using the technique of palpitation during the physical assessment of a patient. Select all that apply. A. The nurse compares the patients bilateral body parts for symmetry. B. The nurse takes a patients pulse C. The nurse touches a patients skin to test for turgor D. The nurse checks a patients lymph nodes for swelling E. The nurse taps a patients body to check the organs F. The nurse uses a stethoscope to listen to a patients heart sounds

B.C.D. During palpitation the nurse uses the sense of touch to take a pulse, test for skin turgor, and check lymph nodes. With inspection, a comparison of bilateral body parts is necessary for recognizing abnormal findings. During percussion, the fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The characteristics of the sounds produced are used to assess the location, shape, size, and density of tissues. Auscultation is the act of listening with a stethoscope to sounds produced within the body

A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short term memory decline E. Decreased risk of depression

B.C.D. Losses in vision, hearing, taste, and smell decline for the client who is aging. Fine finger movement slows, along with some reflex and motor responses for the client who is aging. Minimal decline in short term memory is an expected finding for the client who is aging

A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive wrinkling

B.C.D. Tenting is a delay in the skin returning to its normal place after pinching. Tenting is a manifestation of aging skin and loss of subcutaneous tissue that provides recoil in younger skin. Dehydration can cause the skin to tent, which can easily develop in the older adult client. Tenting in the older adult client is a manifestation of aging skin and loss of elasticity

A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply) A. Collect the data in one continuous session B. Plan to allow plenty of time for position changes C. Make sure the client has any essential sensory aids in place D. Tell the client to take her time in answering questions E. Invite the client to use the bathroom before beginning the examination

B.C.D.E. Plan to allow plenty of time for position changes because many older adults have mobility challenges. Make sure the client has any essential sensory aids in place. The nurse should make sure clients who use sensory aids have them available for use. The client has to be able to hear the nurse and see well enough to avoid injury Tell the client to take her time in answering questions. Some older clients need more time to collect their thoughts and answer questions, but most are reliable historians. Feeling rushed can hinder communication Invite the client to use the bathroom for beginning the examination. This is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who have a smaller bladder capacity

A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (Select all that apply) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature

B.C.E. The nurse should assess the peripheral vascular system to verify adequate circulation to the client's leg, which includes skin color. Pallor and cyanosis reflect inadequate circulation. Edema reflects inadequate venous circulation. Coolness of the extremity compared with the nonoperative extremity indicates inadequate circulation

A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply) A. Address the client with the appropriate title and last name B. Use a mix of open and close ended questions C. Reduce environmental noise D. Have the client complete a printed history form E. Perform the general survey before the examination

B.C.E. Use a mix of open and close ended questions. Open ended questions help the client tell her story in her own way. Closed ended questions are useful for clarifying and verifying information the nurse gathers from the clients story. Reduce environmental noise. A quiet, comfortable environment eliminates distractions and helps the client focus on the important aspects of the interview Perform the general survey before the examination. The general survey is noninvasive and along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the process, such as the examination

A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply) A. Pull the auricle down and back B. Insert the speculum slightly down and forward C. Insert the speculum 2 to 2.5cm D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the tympanic membrane in a cone shape

B.D.E. Inserting the speculum slightly down and forward follows the natural shape of the ear canal. The lining of the ear canal is sensitive. Touching it with the speculum could cause pain. Due to the angle of the ear canal, the nurse can only visualize the light reflecting off of the tympanic membrane as a cone shape rather than a circle

A nurse is assessing a patients eyes for accommodation. What actions would the nurse perform during this test? Select all that apply A. Bring a penlight from the side of the patients face and briefly shine the light on the pupil B. Hold a forefinger, a pencil, or other er straight object about 10-15cm from the bridge of the patients nose C. Hold a finger about 6-8 inches from the bridge of the patient's nose D. Darken the room E. Ask the patient to look straight ahead F. Ask the patient to first look at a close object, then at a distant object, then back to the close object

B.F. To test accommodation the nurse would hold the forefinger, a pencil, or other straight object about 10-15cm from the bridge of the patients nose. Then the nurse would ask the patient to first look at the object, then at a distant object, then back to the object being held. The pupil normally constricts when looking at a near object and dilates when looking at a distant object. To test for convergence, the nurse would darken the room and ask the patient to look straight ahead. The nurse would then bring the penlight from the c side of the patients face and briefly shine the light b on the pupil, observing the reaction. When testing convergence the nurse would hold a finger about 6-8 inches from the bridge of the patients nose and move it toward the patients nose.

A nurse uses observation to examine a patient's skin. Which patient would the nurse document as having cyanosis? A. A patient who presents with redness in the facial area B. A patient who has a yellowish tint C. A patient whose skin is a dusky, bluish color D. A patient whose skin is pale

C. A patient whose skin is a dusky, bluish color

A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers

C. Dorsal surface. The dorsal surface of the hand is the most sensitive to temperature

During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

C. Flatus. With flatus, the protrusion is mainly midline, and there is no change in the flanks

A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as which of the following? A. The patient can see twice as well as normal B. The patient has double vision C. The patient has less than normal vision D. The patient has normal vision

C. Normal vision is 20/20. A finding of 20/40 would mean that a patient has less than normal vision.

Which assessment measure would the nurse use to assess the location, shape, size, and density of a tumor? A. Observation B. Palpation C. Percussion D. Auscultation

C. Percussion

A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the client's ability to perform which of the following activities? A. Mopping her floors B. Brushing back her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink

C. The client who is fastening her bra from behind requires internal rotation of the shoulder, so this activity will elicit pain

During a physical assessment, a nurse inspects a patients abdomen. What assessment technique would the nurse perform next? A. Percussion B. Palpation C. Auscultation D. Whichever is more comfortable for the patient

C. When assessing the abdomen, the sequence is inspection, auscultation, percussion, and Palpation. Auscultation follows inspection because percussion and Palpation stimulate bowel sounds.

After inspecting the skin of a patient, the nurse documents the presence of a skin lesion as a palpable solid mass measured at 1cm. What types of skin lessons might this describe? Select all that apply A. Macule B. Patch C. Plaque D. Nodule E. Bulla F. Pustule

C.D. Plaque and nodules are palpable, elevated, solid masses that may measure 1cm. Macules and patches are circumscribed, flat, non palpable, changes in skin color. Macules are less than or equal to 1cm and patches are greater than 1cm. Bulla and pustules are circumscribed, superficial skin elevations formed by free fluids in a cavity with skin layers. Bulla are greater than 0.5cm and pustules are filled with pus.

A nurse is performing a head and neck examination for an older adult client. Which of the following age related findings should the nurse expect? (Select all that apply) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums

C.D.E. Tooth loss and gum disease are common in older adults Glare intolerance- older adults tend to become intolerant of glaring lights and also lose some ability to distinguish colors. Thickened eardrums- Tympanic membranes (eardrums) thicken in older adults, and they tend to accumulate cerumen in their ear canals

A nurse in the provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V? (select all that apply) A. Close your eyes B. Tell me what you can taste C. Clench your teeth D. Raise your eyebrows E. Tell me when you feel a touch

C.E. Clench your teeth. Testing cranial nerve V, the trigeminal nerve, involves testing the strength of muscle contraction by asking the client to clench their teeth while the nurse palpates the masseter and temporal muscles, and then the temporomandibular joint. Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when they feel a gentle touch on the face from a wisp of cotton

A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Rhonchi B. Crackles C. Resonance D. Tactile remitus E. Bronchovesicular sounds

C.E. Resonance is expected percussion sound over the thorax. It is a hollow sound that indicates air inside the lungs. Bronchovesicular sounds are expected breath sounds of medium pitch and intensity and of equal inspiration and expiration time. The nurse can expect to hear them over the larger airways

A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on his dominant side

C.E. The nurse should expect the client to have a concave lumbar spine posteriorly. The nurse should expect the client to have the muscle size equal on both sides or slightly larger on the dominant side

Common examples of skin lesions in various age groups include the following:

Children -Diaper dermatitis -Intertrigo -Impetigo -Atopic dermatitis (eczema0 Adults: -Primary contact dermatitis -Tinea pedis (ringworm of the foot) -Psoriasis -Labial herpes simplex (cold sores) Older adults: -Lentigines (liver spots) -Seborrheic keratosis -Acrochordons (skin tags) -Sebaceous hyperplasia

Table 25-2 Skin color assessment

Color Variations-Assessment areas- Possible causes Redness (erythema, flushing)- Facial area, localized are of skin on the body- Blushing, alcohol intake, fever, injury, trauma, infection Bluish (cyanosis)- Exposed areas, particularly the ears, lips, inside of the mouth, hands and feet, and nail beds- Cold environment, cardiac or respiratory disease (decreased oxygenation) Yellowish (Jaundice)- Overall skin areas, mucous membranes, and sclera- Liver disease (increase in bilirubin levels) Paleness (Pallor)- Exposed areas, particularly the face and lips, conjunctivae, and mucous membranes- Anemia (decreased hemoglobin) shock (decreased blood volume) Vitiligo (whitish, patchy areas on the skin)- Overall skin areas, lips, nail beds, and conjunctivae- Depigmentation (congenital or autoimmune conditions) Tanned or brown- sun exposed areas- Overexposure (increased melanin production), pregnancy (brown spots)

Table 25-7 Glasgow Coma Scale The Glasgow Coma Scale (GCS) evaluates three key categories of behavior that most closely reflect activity in the higher centers of the brain: eye opening, verbal response, and motor response. Within each category, each level of response is given a numerical value. The maximal score is 15, indicating a fully awake, alert, and oriented patient; the lowest score is 3, indicating deep coma. The GCS is used in conjunction with other neurologic assessments, including pupillary reaction and vital sign measurement, to evaluate a patients status

Component-Score-Response Eye opening : 4- opens eyes spontaneously when someone approaches 3- opens eyes in response to speech (normal tone or shouting) 2- opens eyes only to painful stimuli (apply pressure with a pen to the lateral outer aspect of the second or third finger, up to 10 seconds, then release 1- no response to painful stimuli Motor response: 6- accurately responds to instructions; obeys a simple command, such as lift your left hand off the bed 5- localizes (moves hand to point of stimulation) to painful stimuli and attempts to remove source 4- flexion reflex action, but unable to locate the source of pain; purposeless movement in response to pain 3- flexes elbows and wrists while extending lower legs to pain; decorticate posturing 2- extends upper and lower extremities to pain; decerebrate posturing 1- no motor response to pain on any limb Verbal response: 5- converses; oriented to time, place, and person 4- converses- disoriented to time, place, or person; any one or all indicators 3- converses only in words or phrases that make little sense in the context of the questions 2- Responds with incomprehensible sounds; no understandable words and/or moaning 1- no response

A nurse is assisting with assessment of the internal eye structures of patients in an ophthalmologist's office. What would the nurse document as as a normal finding? A. A uniform yellow reflex B. A clear, reddish optic nerve disc. C. Dark-red arteries and light-red veins D. A reddish retina

D. A reddish retina

The nurse is palpating the skin of a patient and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding? A. Document a normal skin finding on the patient chart B. Assess the patient for cardiovascular disorders C. Report the finding as a positive sign for cystic fibrosis D. Assess the patient for dehydration

D. Assess the patient for dehydration

A nurse is assessing a client's neurosensory system. To evaluate stereognosis, the nurse should ask the client to close his eyes and identify which of the following items? A. A word she whispers 30cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand

D. Identifying a familiar object in the hand confirms the client's sense of stereognosis, which is tactile recognition

When assessing a patients breath sounds, the nurse hears a high pitched continuous sound. What type of breath sound would the nurse document? A. Rhonchi B. Crackles C. Strider D. Wheezes

D. Wheezes are musical or squeaking high pitched, continuous sounds heard as air passes through narrowed airways. Rhonchi are low pitched, continuous sounds with a snoring quality that occur when air passes through secretions. Crackles are bubbling, cracking, or popping, low to high pitched, discontinuous sounds that occur when air passes through fluid in the airways. Stridor is a harsh, loud, high pitched sound due to narrowing of the upper airway.

A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicules? (Select all that apply) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella

D.E. Herpes simplex lesions and Varicella (chickenpox) are vesicles which are circumscribed fluid filled skin elevations. Eczema and impetigo also cause vesicles to appear on the skin.

Box 25-5 Normal heart sounds

During auscultation, the first heart sound, called S1, is heard as the "lub" of "lub-dub". This sounds occurs when the mitral and tricuspid valves close and corresponds to the b onset of ventricular contraction. The sound, low pitched and dull, is heard best at the apical area. The second sound S2 occurs at the termination of systole and corresponds to the onset of ventricular diastole. The "dub" of the "lub-dub" represents the closure of the aortic and pulmonic valves. The sound of S2 is higher pitched and shorter than S1. The two b sounds occur within 1 second or less, depending on the heart rate. Normal findings include S1, that is louder at the tricuspid and apical areas, with S2 louder at the aortic and pulmonic areas

Guidelines for nursing care 25-3 Assessing extraocular movements and peripheral vision

Extraocular movements: -ask the patient to sit or stand about 2 feet away, facing you sitting or standing at eye level with the patient -ask the patient to hold the head still and follow the movement of your forefinger or a penlight with the eyes -keeping your finger out light about 1 foot from the patient's face, move it slowly through the cardinal positions: up and down, left and right, diagonally up and down to the left, diagonally up and down to the right. Peripheral vision: -have the patient stand or sit about 2 feet away, facing you at eye level. -ask the patient to cover one eye with a hand or index card -ask the patient to look directly at your nose and fix the eyes on that spot -cover your own eye opposite the patients closed eye. -hold one arm outstretched to one side (right or left) equidistant from you and the patient, and move you fingers into the visual fields from various peripheral points -ask the patient to tell you when the fi inverses are first seen (both you and the patient should see the fingers at the same time) -repeat the procedure for the other eye

Table 25-8 Full outline of unresponsiveness (Four) Coma Scale The FOUR score coma scale combines the most important neurologic signs into an easy to use scale with four components. The maximum score in each of these components is 4. The components are not totaled or summed and can be used to detect decreasing consciousness, increasing intracranial pressure, and brain herniation, as well as predict patient outcome.

Eye Response: E0 Eyelids remain closed with pain E1 Eyelids closed but open to pain E2 Eyelids closed but open to loud voices E3 Eyelids open but not tracking E4 Eyelids open or opened, tracking or blinking to command Motor Response: M0 No response to pain M1 Extension response to pain M2 Flexion response to pain M3 Localizing to pain M4 Thumbs-up, fist, or peace sign Brainstem Reflexes: B0 Absent pupil, corneal, and cough reflex B1 Pupil and corneal reflexes absent B2 Pupil or corneal reflexes absent B3 One pupil wide and fixed B4 Pupil and corneal reflexes present Respiration: R0 Breathes at ventilator rate or apnea R1 Breathes above venilatory rate R2 Not intubated, irregular breathing R3 Not intubated; Cheyne-Stokes breathing pattern R4 Not intubated, regular breathing pattern

Focused Assessment 25-1 (Pg 629) Health history

Factors to Assess/ Questions and Approaches Present Health history: - When did you first begin having this problem? -Did it happen suddenly or slowly? - Show me exactly where you are having this problem. -What other symptoms have you had with this problem? -How have you treated this problem? Past Health History: -Tell me about your childhood illnesses, such as measles or mumps, that you had. -What are you allergic to? -Describe any accidents, injuries, and surgeries you have had -What prescribed or over the counter medications do you use? - Do you take any herbal or dietary supplements? -What is the date of your most recent immunization for tetanus; pertussis; polio; measles; rubella; mumps; influenza; hepatitis A, B, and C; and pneumococcus? Family History: -How old are the members of your family? -If any members of your family are not living, what caused their death? -Is there any history of this health problem you have in other family members? -Do you have any family members that have long term illnesses Functional Health: -Do you have difficulty or require assistance with bathing or dressing? -Do you have any difficulty or require assistance with toileting or moving around? -Do you have difficulty or require assistance with eating or preparing meals? -Do you have difficulty or require assistance with shopping or administering your own medications? -Tell me about your driving. Who provides transportation -Do you have difficulty or require assistance with housekeeping, finances, or laundry? Psychosocial/Lifestyle Factors: -Do you smoke, drink, or use drugs?If so, what kind, for how long, and how much? -Describe the foods you eat in a typical day. -Tell me about how well you sleep. -How much exercise do you get each day? -Who in your family or community is available to help you with health problems if you need it? -Does your religious faith or spirituality play an important part in your life? -Tell me about how you deal with stress. -Describe any changes that you have had in your mood or feelings. -Have you been treated for any problems with your mood or behavior? -Tell me about your use of seatbelts in cars. -Tell me about your family's use of sports helmets, padding, or other protective equipment.

BP classifications: Stage 2 Hypertension

Greater than 160 Systolic or greater than 100 Diastolic

Identify at least five questions to ask prior to beginning the inspection and palpation portions of the assessment

Have you noticed any changes in your skin color? If so, is the change widespread or just in one area? Do you have a rash? Where? Does it itch? How long have you had it? What have you used to treat the rash? Is your skin excessively dry or oily? Does this change with the seasons? Do you use anything to treat it? Have you developed any new moles or lesions? Have any of the moles or lesions changed in any way (color, borders, size)? How ofter are you out in the sun? Do you use sunscreen or wear protective clothing and a hat? Do you have any swelling? If in your legs, is it in both legs? Does the swelling cause pain? What do you do to relieve the swelling? Does it occur at any particular time of day?

Pulse

Rate- The number of times per minute you feel or hear the pulse Rhythm- The regularity of impulses Strength- Reflects the volume of blood ejected against the arterial wall with each heart contraction and the condition of the arterial vascular system. The strength should be the same from beat to beat. -----Grade scale: 0= absent; 1+= Diminished, weaker than expected; 2+= Brisk, expected; 3+= Increased, strong; 4+= Full Volume, bounding Equality- Peripheral pulse impulses should be symmetrical in quality and quantity from the right side of the body to the left. An inequality or absence of pulse on one side can indicate a disease state.

Age (pulse rate)

Infants 120-160/min 12-14 years old 80-90/min

Table 25-3 Primary skin lesions

Lesion name- description- example Macule- Lesion- less than or equal to 1cm- Petechiae, freckle Patch- Lesion- greater than 1cm- Vitiligo Papule- Mass less than or equal to 0.5cm- mole Plaque- Mass greater than 05.cm- coalesced papules Nodule- Mass 0.5-2cm; firmer than a papule- Nevus (wart) Tumor- Mass greater than 2cm- Lipoma Wheal- Irregular, superficial are of localized skin edema-Hives, mosquito bite Vesicle- filled with serous fluid, less than or equal to 0.5cm-herpes simplex Bulla-filled with serous fluid; greater than 0.5cm- 2nd degree burn Pustule-filled with pus- acne, impetigo

Table 25-4 Secondary and miscellaneous skin lesions

Lesion name-Description-Example Loss of skin surface: Erosion- Loss of superficial , moist, non bleeding surface-Moist area after rupture of a vesicle, as in chickenpox Ulcer- Loss of epidermis and dermis, May bleed and scar- Stasis ulcer Fissure-Deep linear crack, extends into dermis-Athletes foot Material on the skin surface: Crust-Dried residue of serum, pus, or blood-Impetigo Scale-Thin flake of exfoliated dermis-Dandruff, dry skin Miscellaneous lesions: Lichenification-Thickened and roughened epidermis, with increased visibility of skin furrows-Atrophic dermatitis Atrophy-Thinning off the skin, loss of skin furrows, shiny appearance- Peripheral vascular disease Excoriation-Scratching if the epidermis Scar-Fibrous tissue replaces tissue in the dermis or subcutaneous layer Keloid-Hypertrophied scar Other common Skin Lesions, not technically primary or secondary: Comedo- Plugged opening of a sebaceous gland, a hallmark of acne-common blackhead Telangiectasia- Small, dilated, red or bluish surface vessels; may be part of a basal cell carcinoma or a skin injury from radiation Nevus- Flat to slightly elevated, round, evenly pigmented-common mole

List seven key chest landmarks, along with their location on the thorax

Midsternal line: through the center of the sternum Midclavicular line: through the midpoint of the clavicle Anterior axillary line: through the anterior axillary folds Midaxillary line: through the apex of the axillae Posterior axillary line: through the posterior axillary fold Right an left scapular lines: through the inferior angle of the scapula Vertebral line: along the center of the spine

Table 25-9 Summary of Cranial Nerves

Nerve (Number)-Type-Functions-Methods for Examining Nerve Olfactory (1)-Sensory- Sense of smell- Test each nostril for smell reception with various agents and interpretation Optic (II)- Sensory-Sense of vision- Test vision for acuity and visual fields Oculomotor (III)-Motor- Pupil constriction/raise eyelids- Test pupillary reaction to light and ability to open and close eyelids Trochlear (IV)- Motor-Proprioceptor- Downward, inward eye movement- Test for downward and inward movement of the eye Trigeminal (V)- Motor- Jaw movements, chewing and mastication- Ask patient to open and clench jaws while you palpate the jaw muscles Trigeminal (V)- Sensory- Sensation on the neck and face-Test face and neck for pain sensations, light touch, and temperature Abducens (VI)- Motor- Lateral movement of the eyes- Test ocular movement in all directions Facial (VII)- Motor- Muscles of the face- Ask the patient to raise eyebrows, smile, show teeth, and puff out cheeks Facial (VII)- Sensory- Sense of taste on the anterior two thirds of the tongue- Test for the taste sensation with various agents. Acoustic (VIII)-Sensory- Sense of hearing- Test hearing ability Glossopharyngeal (IX)- Motor- pharyngeal movement and swallowing- Ask the patient to say ah and have patient yawn to observe upward movement of the soft palate Glossopharyngeal (IX)-Sensory- Sense of taste on the posterior one third of the tongue- Test for taste with various agents Vagus (X) Motor/Sensory- Swallowing and speaking- Ask the patient to swallow and speak; note hoarseness Accessory (XI) Motor/Sensory- Movement of shoulder muscles- Ask the patient to shrug shoulders against your resistance Hypoglossal (XII) Motor- Movement of the tongue; strength of the tongue- Ask the patient to protrude tongue; ask the patient to push tongue against cheek

Respiriation

Rate: The number of full inspirations and expirations in 1 min. Observe the number of times the client's chest rises and falls. Expected range for adults is 12-20/min Depth: The amount of chest wall expansion that occurs with each breath. Altered depths are deep and shallow Rhythm: The observation of breathing intervals. Eupnea- regular rhythm

Expected Temperature Ranges

Oral- 36-38 (96.8-100.4) is acceptable. Average is 37 (98.6) Rectal- usually 0.5(0.9) higher than oral or tympanic temperatures Axillary- usually 0.5(0.9) lower than oral and tympanic temperatures Temporal-close to rectal, but nearly 0.5(1) higher than oral and 1 (2) higher than axillary *A client's usual temperature serves as a baseline for comparison*

PERRLA (CN II, CN III)

P - Pupils should be clear E - Equal in size and between 3 to 7 mm in diameter R - Round in shape R - Reactive to light both directly and consensually when a light is directed into one pupil and then the other L - Light A - Accommodation of the pupils when they dilate to look at an object far away and then CONVERGE and CONSTRICT to FOCUS on a near object.

Box 25-6 Components of a neurovascular assessment

Pain: Extreme pain, especially on a passive motion, is a significant sign of probable neurovascular impairment in an extremity. Subjective and objective assessments should be included. Opioid analgesia is unlikely to relieve the pain. Pallor (perfusion): Comparison between affected and unaffected limb is important. Assess color and temperature of the extremity. Pale skin, decreased tone, or white color may indicate poor arterial perfusion. Cyanosis may indicate venous stasis. Coolness or decreased temperature may indicate decreased arterial supply. Compare distal to proximal temperature variation in affected limb. Assess capillary refill. Peripheral pulses: Comparison between affected and unaffected limb is important. Assess the consistency of arterial blood flow (pulse presence, rate, quality) to and past the affected area. Assess capillary refill, especially in patients whose pulses cannot be palpated due to casts or bandages and in nonverbal patients. Paresthesia (sensation): May be first symptom of changes in sensory nerves to appear. Numbness, tingling, or "pins and needles" sensations may be reported. Evaluate the areas above and below the affected area. Paralysis (movement): The ability of the patient to move the extremity distal to the injury. Paralysis of an extremity may be the result of prolonged nerve compression or irreversible muscle damage. Pressure: Comparison between affected and unaffected limb is important. Affected area may become taut and firm to the touch, with surrounding skin appearing shiny. The feeling of tightness or pressure may be present.

Table 25-1 Characteristics of masses determined by palpation

Quality and characteristics to determine Shape: Round; Ovoid; Tubular; Irregular Size: Measured in cm Consistency: Firm; Edematous; Spongy; Cystic Surface: Smooth; Nodular; Granular Mobility: Fixed or nonmobile; Mobile Tenderness: Amount of tenderness to touch Pulsatile: Pulsation can or cannot be felt in the mass

Box 25-2 Positions used during physical assessment

Standing: The patient stands erect. This position should not be used for patients who are weak, dizzy, or prone to fall. It is used to assess posture, balance, and gait (while walking upright) Sitting: The patient may sit in a chair or on the side of the bed or examining table, or remain in bed with the head elevated. It allows visualization of the upper body, facilitates full lung expansion, and is used to assess vital signs and the head, neck, anterior and posterior thorax, lungs, heart, breasts, and upper extremities. Supine: The patient lies flat on the back with legs extended and knees slightly flexed. It facilitates abdominal muscle relaxation and is used to assess vital signs and the head, neck, anterior thorax, lungs, heart, beasts, abdomen, extremities, and peripheral pulses. Dorsal Recumbent: The patient lies on the back with legs separated, knees flexed, and the soles of the feet on the bed. It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. It should not be used for abdominal assessment because it causes contraction of the abdominal muscles. Sims Position: The patient lies on either side with the lower arm below the body and the upper arm flexed at the shoulder and elbow. Both knees are flexed, with the upper leg more acutely flexed.It is used to assess the rectum or vagina. Prone: The patient lies flat on the abdomen with the head turned to one side. It is used to assess the hip joint and the posterior thorax. Lithotomy: The patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and the heels in stirrups. It is used to assess female genitalia and rectum. Knee-chest:The patient kneels with the body at a 90 degree angle to the hips, back straight, arms above the head. It is used to assess the anus and rectum.

BP classification: Normal

Systolic <120 Diastolic <80

Pulse deficit

The difference between the apical rate and radial rate. To determine the pulse rate deficit accurately, two clinicians should measure the apical and radial pulse rates simlutaneously

Table 25-6 Adventitious breath sounds

Type and characteristics: Wheeze (sibilant) -musical or squeaking -high-pitched, continuous sounds -auscultated during inspiration and expiration -air passing through narrowed airways Rhonchi (sonorous wheeze) -sonorous or coarse; snoring quality -low pitched, continuous sounds -auscultated during inspiration and expiration -coughing may clear the sound somewhat -air passing through or around secretions Crackles: -bubbling, crackling, popping -low to high pitched, discontinuous sounds -auscultated during inspiration and expiration -opening of deflated small airways and alveoli; air passing through fluid in the airways Stridor: -harsh, loud high pitched -auscultated on inspiration -narrowing of upper airway (larynx or trachea); presence of foreign body in airway Friction rub: -rubbing or grating -loudest over lower lateral anterior surface -auscultated during inspiration and expiration -inflamed pleura rubbing against chest wall

Box 25-4 Assessing for Melanoma

Warning signs: The ABCDEs of Melanoma A: Asymmetry- If a line is drawn through a mole; the two halves will not match B: Border- The borders of an early melanoma tend to be uneven. The edges may be scalloped or notched C. Color- Having a variety of colors is another warning signal. A number of different shades of brown, tan, or black could appear. A melanoma may also become red, blue, or some other color. D. Diameter- Melanomas usually are larger in diameter than the size of the eraser on your pencil (1/4inch or 6mm), but they may sometimes be smaller when first detected E. Evolving- Any change- in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting- points to danger

A nurse is conducting an assessment of a patients cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show teeth to assess which cranial nerve? A. Olfactory B. Optic C. Facial D. Vagus

c. Motor function of the facial nerve (cranial nerve VII) is assessed by asking the patient to raise the eyebrow, smile, and show the teeth. The olfactory nerve (cranial nerve I) is tested by testing smell reception with various agents. The nurse tests the optic nerve (cranial nerve II) for acuity and visual fields and the vagus nerve (cranial nerve X) by asking the patient to swallow and speak, noting hoarseness.