Chapter 16: Health Assessment and Physical Examination

a nurse reviews a chart and sees that a patient who has been admitted to the unit this morning has a hyperthyroid disorder. the nurse anticipates that an examination of his eyes will reveal: 1. diplopia 2. strabismus 3. exopthalmos 4. nystagmus

3. exopthalmos

a patient in a physician's office has an increased anteroposterior diameter of the chest. the nurse should inquire specifically about the patient's history of: 1. smoking 2. thoracic trauma 3. spinal surgery 4. exposure to tuberculosis

1. smoking

to inspect an adult patient's ear canal, the nurse pulls the auricle: 1. up and back 2. down and back

1. up and back

a nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale. the following findings are documented: eyes open to speech, responses are oriented, localized pain is noted. the score for this patient is: 1. 15 2. 13 3. 11 4. 9

2. 13

a patient has an area of discomfort. the nurse will examine this area: 1. first 2. last

2. last

a patient with asthma has gone to an urgent care center for treatment. on auscultation of the lungs, a nurse hears rhonchi. these sounds are described as: 1. dry and grating 2. loud, low-pitched, and coarse 3. high-pitched, fine, and short 4. high-pitched and musical

2. loud, low-pitched, and coarse

a young adult woman arrives at the family planning center for a physical examination. for this patient with mature breasts, the nurse expects to find that the: 1. breast tissue is softer 2. nipples project and areolae have receded 3. areolae are dark and have increased diameter 4. breasts are elongated and nipples are smaller and flatter

2. nipples project and areolae have receded

a patient in the physician's office informs you that he is having trouble hearing when other people are seeking to him. a. what specific assessments will you perform on this patient?

- have the patient remove any hearing aid if worn - note the patient's response to questions. normally the patient responds without excess requests to have questions repeated. - if you suspect a hearing loss, check the patient's response to the whispered voice. test one ear at a time while the patient occludes the other ear with a finger. ask the patient to gently move the finger up and down during the test. while standing 30 cm to 60 cm from the testing ear, cover your mouth so the patient is unable to read lips. after exhaling fully, whisper softly toward the unoccluded ear, reciting random numbers with equally accented syllables such as nine-four-ten.. if necessary, gradually increase voice intensity until the patient correctly repeats the numbers. then test the other ear for comparison.

identify what a nurse is able to assess in a general survey of a patient:

- primary health problems - behavior and appearance - hygiene, skin condition, and body image; emotional state; recent changes in weight; and developmental status

light palpation involves depressing the part being examined: 1. 1/2 inch 2. 1 inch 3. 1 1/2 inches 4. 2 inches

1. 1/2 inch

when auscultating a patient's chest, a nurse hears what appears to be an S3 sound. this is an expected finding if the patient is: 1. 10 years old 2. 35 years old 3. 56 years old 4. 82 years old

1. 10 years old

Screenings are being conducted at the junior high school for scoliosis. A nurse is observing the students for the presence of: 1. an S-shaped curvature of the spine 2. an exaggerated curvature of the thoracic spine 3. an exaggerated curvature of the lumbar spine 4. a bulging of the cervical vertebrae and disks

1. an S-shaped curvature of the spine

when teaching a 45-year-old patient in the gynecologist's office about breast cancer, a nurse includes information on recommendations for screening. the patient is informed that women her age should have: 1. annual mammograms 2. biannual CT scans 3. physical examinations every 3 years 4. breast self-examinations

1. annual mammograms

a patient in a rehabilitation facility has experienced a cerebrovascular accident (CVA/stroke) that has left the patient with an expressive aphasia. the nurse anticipates that this patient will: 1. be unable to speak or write 2. be unable to follow directions 3. respond inappropriately to questions 4. have difficulty interpreting words and phases

1. be unable to speak or write

when using the stethoscope, high-pitched sounds are heard best with a: 1. diaphragm 2. bell

1. diaphragm

a patient is admitted to a medical center with peripheral vascular problem. a nurse is performing the initial assessment of the patient. while assessing the lower extremities, the nurse is alert to venous insufficiency as indicated by: 1. marked edema 2. thin, shiny skin 3. coolness to touch 4. dusky red coloration

1. marked edema

a nurse has checked the medical record and found that a patient has anemia. the presence of anemia is accompanied by the nurse's finding of: 1. pallor 2. erythema 3. jaundice 4. cyanosis

1. pallor

while reviewing a medical record, a nurse notes that a patient has suspected pancreatitis. the nurse assesses the patient for: 1. positive rebound tenderness 2. midline abdominal pulsations 3. hyperactive bowel sounds in all quadrants 4. bulging of the flanks with dependent distention

1. positive rebound tenderness

student nurses are practicing neurological assessment and determination of cranial nerve functioning. to assess cranial nerve X, the student nurse should ask the patient to: 1. say "ah" 2. shrug the shoulders 3. smile and frown 4. stick out the tongue

1. say "ah"

an 80-year-old woman is being assessed by a nurse in an extended care facility. the nurse is assessing the genitalia of this patient and suspects that there may be a malignancy present. the nurse's suspicion is due to the finding of: 1. scaly, nodular lesions 2. yellow exudates and redness 3. small ulcers with serous drainage 4. extreme pallor and edema

1. scaly, nodular lesions

to assess a patient's visual fields, a nurse should: 1. ask a patient to read text 2. turn the room light on and off 3. move a finger at arm's length toward the patient from an angle 4. shine a penlight into the patient's eye at an oblique angle

3. move a finger at arm's length toward the patient from an angle

the patient needs to sit upright to breathe easier. this is recorded by the nurse as: 1. apnea 2. dyspnea 3. orthopnea 4. tachypnea

3. orthopnea

a nurse manager observes a new nurse on the unit performing a patient assessment. the new nurse's assessment should be interrupted if the manager observes the nurse: 1. using the pads of the first three fingers to palpate the breast tissue 2. auscultating the abdomen continuously for 5 minutes 3. palpating both carotid arteries simultaneously 4. testing sensory function on random locations with the patient's eyes closed

3. palpating both carotid arteries simultaneously

a nurse exerts downward pressure on the thigh. this assessment is determining the muscle strength of the: 1. triceps 2. trapezius 3. quadriceps 4. gastrocnemius

3. quadriceps

a nurse teaches the male patient that he should notify a health care provider if he finds the following during a testicular self-examination: 1. loose, deeper color scrotal skin with a coarse surface 2. cordlike structures on the top of the testicles 3. small, pea-sized lumps on the front of the testicle 4. smegma under the foreskin

3. small, pea-sized lumps on the front of the testicle

a patient with a history of smoking and alcohol abuse has gone to a clinic for a physical examination. based on this history, the nurse is particularly alert during an examination of the oral cavity to the presence of: 1. spongy gums 2. pink tissue 3. thick, white patches 4. loose teeth

3. thick, white patches

a patient has been experiencing some lightheadedness and loss of balance over the past few weeks. a nurse wants to check the patient's balance while waiting for the patient to have other laboratory tests. the nurse administers the: 1. Allen test 2. Rinne test 3. Weber test 4. Romberg test

4. Romberg test

a nurse is assessing a patient's nail beds. an expected finding is indicated by: 1. softening of the nail bed 2. a concave curve to the nail 3. brown, linear streaks in the nail bed 4. a 160-degree angle between the nail plate and nail

4. a 160-degree angle between the nail plate and nail

a screening for osteoporosis is being conducted at an annual health fair. to determine the risk factors for osteoporosis, a nurse is assessing individuals for: 1. multiparity 2. a heavier than recommended body frame 3. an African American background 4. a history of dieting and/or alcohol abuse

4. a history of dieting and/or alcohol abuse

a patient in a medical center has been prescribed bed rest for a prolonged period of time. there is a possibility that the patient may have developed phlebitis. the nurse assesses for the presence of this condition by: 1. palpating the ankles for pitting edema 2. checking the popliteal pulses bilaterally 3. inspecting the thighs for clusters of ecchymosis 4. checking the appearance and circumference of the lower legs

4. checking the appearance and circumference of the lower legs

a nurse assessed a patient's skin and documents that vesicles are present. this observation is based on the nurse finding: 1. flat, nonpalpable changes in skin color 2. palpable, solid elevations smaller than 1 cm 3. irregularly shaped, elevated areas that vary in size 4. circumscribed elevations of skin filled with serous fluid

4. circumscribed elevations of skin filled with serous fluid

to assess the temperature of the patient's skin, the nurse should use the: 1. thumbs 2. fingertips 3. palm of the hand 4. dorsal surface of the hand

4. dorsal surface of the hand

a nurse is performing a complete neurological assessment on a patient after a cerebrovascular accident (CVA/stroke). to assess cranial nerve III, the nurse: 1. uses the Snellen chart 2. lightly touches the cornea with a wisp of cotton 3. whispers into one ear at a time 4. measures pupil reaction to light and accommodation

4. measures pupil reaction to light and accommodation

in preparation for an examination of the internal ear, a nurse anticipates that the color of the eardrum should appear: 1. white 2. yellow 3. slightly red 4. pearly gray

4. pearly gray

while completing a physical examination, a nurse assesses and reports that a patient has petechiae. the nurse has found: 1. light perspiration on the skin 2. moles with regular edges 3. thickness on the soles of the feet 4. pinpoint-size, flat, red spots

4. pinpoint-size, flat, red spots

an irregular pulse is counted for _____ seconds

60

you observe a lesion on the patient's abdomen that is draining fluid. a. what specific assessments should be made? b. how should you prepare to assess the lesion?

a. lesion:location, size, shape, depth, and color drainage: amount, color, consistency, and odor b. after explaining the procedure, providing privacy, positioning the patient either dorsal recumbent or side-lying, and making sure there is adequate lighting, you should apply gloves and examine the area gently.

patients older than 65 years should be instructed to have yearly eye examinations TRUE or FALSE

TRUE

what is used to weigh the following patients? a. newborn infant b. mobile adult

a. basket or platform scale b. a platform scale

choose whether each of the following assessment findings is EXPECTED or UNEXPECTED. for unexpected findings, investigate what may be the possible etiology. a. skin lifts easily and snaps back b. erythema noted over bony prominences c. hair evenly distributed over scalp and pubic area d. brown pigmentation of nails in longitudinal streaks (dark-skinned patient) e. pallor in face and nail beds f. clubbing of nails g. PEERLA h. pupils cloudy i. yellow discoloration of sclera j. eardrum translucent, shiny, and pearly gray k. light brown or gray cerumen l. nasal septum midline m. nasal mucosa pale with clear, watery discharge n. sinuses tender to touch o. teeth chalky white, with black discoloration p. tongue medium red, moist, and slightly rough on top q. soft palate rises when patient says "ah" r. uvula reddened and edematous, tonsils with yellow exudate s. thyroid gland small, smooth, and free of nodules t. lungs resonant to percussion u. costal angle greater that 90 degrees between costal margins v. bulging of intercostal spaces w. no carotid bruit present x. extra heart sound noted y. jugular vein distention at 45-degree angle z. dependent edema in ankles aa. female breasts smooth, symmetrical, without retraction bb. soft, well-differentiated, moveable lumps in the breasts noted cc. bowel sounds active and audible in all four quadrants dd. bulging flanks ee. flat or concave umbilicus ff. rebound tenderness found gg. perineal skin smooth and slightly darker than surrounding skin hh. Bartholin glands palpable with discharge evident ii. glans penis smooth and pink on all surfaces jj. testes smooth and ovoid kk. no crepitus found on range of motion ll. hips and shoulders aligned parallel mm. lordosis of spine noted nn. reflexes symmetrical oo. able to recall past events, unable to repeat series of five numbers pp. able to perform rapidly alternating movements

a. expected b. unexpected c. expected d. expected e. unexpected f. unexpected g. expected h. unexpected i. unexpected j. expected k. expected l. expected m. unexpected n. unexpected o. unexpected p. expected q. expected r. unexpected s. expected t. expected u. expected v. unexpected w. expected x. unexpected y. unexpected z. unexpected aa. expected bb. unexpected cc. expected dd. unexpected ee. expected ff. unexpected gg. expected hh. unexpected ii. expected jj. expected kk. expected ll. expected mm. unexpected nn. expected oo. unexpected pp. expected

the nurse is preparing to do an assessment of the abdomen. a. the correct sequence for the abdominal exam is: b. bowel sounds usually occur _____/minute c. what finding is expected for the patient with ascites? d. absent bowel sounds can result from:

a. inspection, auscultation, palpation, percussion b. 5 - 35 c. distended abdomen, taut skin, and bulging flanks d. lack of peristalsis, bowel obstruction, paralytic ileus (decreased or absent peristalsis), or peritonitis (inflammation of the peritoneum)

what techniques are appropriate when assessing patients of different ages? a. speaking privately with adolescents about their concerns b. using closed-ended questions to increase the speed of the examination c. calling children and their parents by their first names d. providing time for children to play e. performing the examination for an older adult near bathroom facilities f. proceeding rapidly through the examination of an older adult to finish it as quickly as possible

a. speaking privately with adolescents about their concerns d. providing time for children to play e. performing the examination for an older adult near bathroom facilities

loss of hair

alopecia

to assess for a pulse deficit, the nurse should:

auscultate the apical pulse first and then immediately assess the radial pulse (one-examiner technique). assess the apical and radial rates at the same time when two examiners are present. when a patient has a pulse deficit, the radial pulse is slower than the apical

identify all of the risk factors for breast cancer. a. under 40 years old b. recent use of oral contraceptives c. late onset menarche d. family history e. childless

b. recent use of oral contraceptives d. family history e. childless

what are the risk factors associated with osteoporosis? a. an active lifestyle b. smoking c. African American background d. a history of falls e. a history of Cushing disease f. exposure to sunlight g. a thin, light body frame

b. smoking d. a history of falls e. a history of Cushing disease g. a thin, light body frame

a patient is suspected of substance abuse. what physical findings would be found on the skin? a. loss of pigment b. spider angiomas c. hematomas d. red, dry areas e. burns on the fingers f. irregularly shaped moles

b. spider angiomas d. red, dry areas e. burns on the fingers

select the three best positions that a patient may be placed in for a cardiac assessment: a. prone b. supine c. lithotomy d. sitting e. left lateral recumbent f. dorsal recumbent g. Sims

b. supine d. sitting e. left lateral recumbent

blowing, swishing sound in blood vessel

bruit

a nurse is preparing to perform a skin assessment for an average adult patient. select all of the following appropriate techniques a. using fluorescent lighting b. keeping the room very warm c. using disposable gloves to inspect lesions d. looking for coloration changes by checking the tongue and nail beds

c. using disposable gloves to inspect lesions d. looking for coloration changes by checking the tongue and nail beds

identify signs and symptoms that a patient may have if he or she has cardiopulmonary disease

chest pain or discomfort, palpitations, excess fatigue, cough, dyspnea, edema of the feet, cyanosis, fainting, or othopnea

the position to place the patient in for an abdominal examination is:

dorsal recumbent

fluid accumulation, swelling

edema

a red discoloration

erythema

one example of a test for colorectal cancer is:

fecal immunochemical test (FIT), fecal occult blood test (FOBT), colonoscopy, and barium enema

a weight gain of 5 lb or 2.2 kg/day indicates:

fluid retention

you are assigned to assist with physical examinations in the outpatient clinic. on the schedule for today are three patients. one of the patients is a 72-year-old Hispanic woman, another is a 16-year-old girl, and the last is a 4-year-old boy. a. how can you assist each of these patients to feel more at ease before and during the physical examination?

for each of the patients, opportunity should be provided to use the bathroom before, during, and after the examination. - the older Hispanic woman may have responses to the examination that are influenced by her culture. She will need to be informed and prepared for the breast and pelvic assessments, with consideration given to her privacy. this patient may desire another woman to be present during the examination or to conduct the physical. care should be taken to determine that this patient understands the information and instruction provided by an examiner who may speak only English. an interpreter may be obtained if the patient is conversant in Spanish. the environment should be warm and comfortable. ample time should be allowed for the patient to answer questions and assume necessary positions for the exam. - for the 16-year-old girl, the nursery begin the health assessment with the parent(s) in the room with the patient. there should be time, however, when the patient is by herself with the nurse to discuss concerns. the adolescent girl should be asked if she would like a parent present during the physical assessment, but the option is provided for the patient to not be accompanied. procedures and findings should be explained to the parent(s) and the patient. - for the 4-year-old boy, you are aware that the experience may be new and frightening. you can show the child the assessment procedures on a doll or model, while giving simple, understandable information, and he may handle equipment that may be used (as appropriate). the exam should be conducted in a comfortable environment, with time allowed for the child to play. the child may be called by his first name, and he may be asked assessment questions that he will understand.

a hardened area

induration

identify the five skills used in physical assessment and briefly describe each

inspection: use of vision and hearing to detect characteristics of body parts and functions palpation: use of the hands to touch body parts to determine temperature, texture, position, and movement percussion: striking the body surface with the finger to produce a vibration and elicit sounds auscultation: listening to sounds created in the body organs (use of stethoscope) olfaction: use of smell to determine the presence of characteristic odors

yellow-orange discoloration

jaundice

curvature of the thoracic spine

kyphosis

the position to place the patient in for a genital examination is:

lithotomy

black, tarry stools

melena

continuous dilation of the pupils is found with the patient experiencing:

neurological pathologies, glaucoma, opioid withdrawal and trauma, or taking ophthalmic medication

tiny, pinpoint red spots on the skin

petechiae

drooping of eyelid over the pupil

ptosis

how can the nurse test recent and past memory?

recent memory can be tested by asking the patient to recall by repeating a series of numbers in the order they are presented or in reverse order. patients normally recall 5 to 8 digits forward, or 4 to 6 digits backward. another test for recent memory involves asking the patient to recall events occuring during the same day. 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.

the primary nurse tells the student that the patient is experiencing tinnitus. the student expects that the patient will describe:

ringing in the ears

when teaching the patient about the signs and symptoms of prostate cancer, the nurse should include what information?

signs and symptoms include weak or interrupted urine flow, an inability to urinate, difficulty in starting or stopping the urine flow, polyuria, nocturia, hematuria, dysuria, or continuing pain in the lower back, pelvis, or upper thighs

during a physical examination, a nurse notes that the patient appears to be very anxious. the nurse should:

stop the examination, explain what is happening, ask the patient how he/she is doing, and postpone the procedure, if indicated

an expected response when testing the pupils for accommodation is:

the pupils will converge and accommodate by constricting when looking at close objects. the pupil responses are equal

identify at least two techniques that are used in assessment of the lymph nodes

use of a methodical approach to avoid overlooking any single node or chain. example: neck: the patient relaxes with the neck flexed slightly forward. inspect and palpate both sides of the neck for comparison. during palpation either face or stand to the side of the patient for easy access to all nodes. using the pads of the middle three fingers of each hands, gently palpate in a rotary motion over the nodes. to palpate supraclavicular nodes, ask the patient to bend the head forward and relax the shoulders. palpate these nodes by hooking the index and third finger over the clavicle, lateral to the sternocleidomastoid muscle. palpate the deep cervical nodes only with the fingers hooked around the sternocleidomastoid muscle. axilla: palpate the axillary nodes with the fingertips gently rolling soft tissue. normally lymph nodes are not palpable. not the number, consistency, mobility, and size of palpable nodes.

three possible causes of hearing loss are:

working or living around loud noises, premature hearing loss from continued exposure to loud music through earbuds connected to electronic music devices or loud concerts, deterioration of the cochlea and thickening of the tympanic membrane in older adults, ototoxicity resulting from high maintenance doses of antibiotics (e.g. aminoglycosides)