physical assessment

Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply. Slowed movement Cartilage degeneration Increased bone density Increased range of motion Increased bone prominence

slowed movement, cartilage degeneration, increased bone prominence

A nurse is assessing an older adult male client. Which clinical findings are expected responses to the aging process? Slowed neurologic responses Lowered intelligence quotient Long-term memory impairment Forgetfulness about recent events Reduced ability to maintain an erection

slowed neurological responses, forgetfulness about recent events, reduced ability to maintain an erection

Which diagnostic study is used to determine a client's bone density?

standard X-ray

A nurse who is assessing a full-term newborn elicits the Moro reflex. Which method would the nurse utilize to best elicit this reflex? Touching the infant's cheek Striking the surface of the infant's crib suddenly Allowing the infant's feet to touch the surface of the crib Stroking the sole of the foot along the outer edge from the heel to the toe

striking the surface of the infant's crib suddenly

is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses

supine

Heart rate of above 100 bpm

tachycardia

Respiratory rate above 20

tachypnea

A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. Which assessment is the priority?

take the patients pedal pulse

what are some limits for patients to not be able to sit?

weak, unable to sit

High-velocity airflow through severely narrowed or obstructed airways results in a ______________ sound heard all over the lungs

wheezing

jaundice

yellowing of the skin

described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.

crackles

areas greater than 6 mm

diameter

A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? Report of pain when taking deep breaths Client is observed splinting the fracture site Diminished breath sounds on the affected side Bowel sounds are auscultated in the lower chest

diminished breath sounds on the affected side

What body position is where the patient lies on their back with the knees bent

dorsal recumbent

shortness of breath

dyspnea

what are some limitations/ considerations of the knee chest position

embarrassing/ uncomfortable (AWK)

turning the ankle inward toward the midline of the body

eversion

A nurse is demonstrating to a client how to manipulate the ankles through full range of motion. Which movements should the nurse use during this process?

eversion, inversion, dorsiflexion, plantar flexion

high pitched fine, short, interrupted crackling sounds heard during end of inspiration, usually not cleared by cough

fine crackles

Coughing up blood from the respiratory tract

hemoptysis

what are some limitations of the supine position?

if patient becomes short of breath raise the head of the bed!

A nurse performing a newborn assessment elicits the Babinski reflex. What does the nurse conclude that this finding indicates?

immaturity of the central nervous system

How do you prepare for a physical exam

infection control, environment, equipment, physical preparation, psychological

what order does an abdominal exam go in

inspection, auscultation, percussion, palpation

what order does an exam go in

inspection, palpation, percussion, auscultation

is turning the ankle outward away from the midline of the body.

inversion

what are some limitations of the sims position

joint difformities hinder patients ability to bend hips and knees

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? Assess the client's lungs. Assess the client for pain. Obtain details of smoking habits. Ask about the onset of breathlessness.

assess the lungs

uneven shape

asymmetry

What things do you look for in skin lesions

asymmetry, border irregularity, color, diameter

cyanosis

bluish discoloration of the skin

edges blurred, notched, ragged

border irregularity

Heart rate less than 60 bpm

bradycardia

Respiratory rate less than 12

bradypnea

While assessing a client with a musculoskeletal disorder, the nurse gives the client a muscle strength rating of 3. What observation would correspond to this rating?

can complete ROM against gravity

The nurse recognizes that which are important components of a neurovascular assessment? Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation

capillary refill, pulse and skin temp, movement and sensation

occurs when there is decreased blood flow or injury to the brain stem that affects breathing

cheyne stokes

rate of depth are irregular alternating periods of apnea and hyperventilation

cheyne-stokes

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences?

chinese americans

loud, bubbly sounds heard during inspirations, not cleared with coughing

coarse crackles

Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucous is present in the larger airways

coarse rhonci

what body position has patients knees on the bed (back and stomach are not touching bed)

knee chest

While assessing a client's musculoskeletal system, the nurse identifies genu valgum. Which joint might have been palpated by the nurse?

knee joint

is indicated for rectal assessment

knee-chest

hunchback

kyphosis

Why do nails club?

lack of oxygen, heart or pulmonary disease

what body position has patients laying on side with legs bent

lateral recumbent

What body position is supine?

laying down

What body position is laying on back, feet up in stirrups, knees bent

lithotomy

increased lumbar curvature

lordosis

lower, moister sounds heard during middle of inspiration, not cleared with coughing

medium crackle

what are some limitations/ considerations of the lithotomy position?

minimize time patient spends in position (AWKWARD)

A nurse is auscultating a client's heart sounds and hears S 1. Which valves is the nurse assessing? Mitral and tricuspid Aortic and tricuspid Mitral and pulmonic Aortic and pulmonic

mitral and tricuspid

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. Which type of lung sounds will the nurse hear? Snorting sounds during the inspiratory phase Moist rumbling sounds that clear after coughing Musical sounds more pronounced during expiration Crackling inspiratory sounds unchanged with coughing

moist rumbling sounds that clear after coughing

What site do you hear the crackling of the lungs

most common in dependent lobes

After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this assessment?

motor function

What is the cause of Rhonci sounds in the lungs

muscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulence

A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority? warmth numbness peeling of the skin discomfort

numbness

person must sit or stand to breathe comfortably

orthopnea

pallor

paleness

What are some limitations that follow dorsal recumbent

patients with painful disorders

what are some limitations of lateral recumbent

patients with respiratory difficulties

what are some limitations of the prone position

patients with respiratory difficulties

when you touch the skin and it indents put does not rise back

pitting edema

Which action performed by the nursing student during the chest examination of a client needs correction? Placing the stethoscope over bony prominences Palpating two ribs inferiorly in the midaxillary line Dividing the anterior and posterior lungs into thirds Listening to at least one cycle of inspiration and expiration

placing the stethoscope over bony prominences

are of a dry or grating quality that is heard in the lower portion of the anterior lateral lung, as observed in client

pluera rub

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties?

prone

is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well

prone

what body position is on stomach and arms folded above head

prone

what does PERRLA stand for

pupils equal, round, reactive to light and accommodation

what is the cause of crackling in the lungs?

random, sudden reinflation of groups of the alveoli, disruptive passage of air through small airways

erythema

redness of the skin

patients should hear air conducted sound twice as long as bone

rhine test

Loud, low pitched, rumbling, coarse sounds are heard either during inspiration or expiration; sometimes cleared by coughing

rhonchi

particularly on expiration, indicate partial airway obstruction because of bronchiolar alterations associated with COPD and usually clear with coughing. Snorting sounds are made in the nose. Wheezes are musical sounds usually heard during expiration; they are caused by rapid vibration of bronchial walls. Crackling sounds heard on inspiration that are unchanged by coughing are known as fine crackles; they result when air passes through alveoli that partially are filled with fluid.

coarse rhonci

pigmentation not uniform

color

Primarily head over trachae and bronchi if loud enough able to be heard over most lung feilds

rhonchi

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as?

contracture

lateral S-shaped curvature of the thoracic and lumbar spine

scoliosis

lateral spinal curvature

scoliosis

What is the body position on stomach with one leg bent up?

sims

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? Vesicular Bronchial Crackles Rhonchi

crackles

is indicated to assess the rectum and vagina.

sims

irregular heart beat

arrhythmia

pitting edema +1

2 mm

+2

4mm

3+

6 mm

4+

8 mm

what parts of the heart produce the S2 sounds

The aortic and pulmonic

During auscultation of the heart, where does the nurse expect the first heart sound (S 1) to be the loudest?

apex of the heart

without breathing

apnea