Chapter 20: Health History and Physical Assessment

What are the preventive strategies that the nurse can teach the patient in relation to glaucoma:

Regular exams from optometrist Always wear protective eyewear Limit caffeine Increase physical activity

Identify patient safety concerns that may be determined during the assessment (2-3)

- How the patient moves/ambulates - The use of assistive devices - Overall status and alertness

When may a third person be present in the room during a physical examination? (4)

- If the patient requests for someone to be there - If there is a safety need for both the N & P that requires it - Patient is a minor - The nurse's gender is different from that of the patient

For an assessment of the hair and nails, which are expected findings? a. Nail bed light pink to reddish-brown tinged b. 160 degree angle between the nail and nail plate c. Alopecia d. Pruritus e. Capillary refill of 10 seconds f. Dry, brittle hair

- Nail bed pink to reddish-brown tinged - 160 degree angle between the nail and nail plate

How can the patient's fine motor skills and function be tested? (3)

- Passing one object from one hand to the other - Picking up 2 or more objects in the same hand - Turning pages 1 at a time - Writing a signature

For an assessment of the skin, identify all of the expected findings. a. Pallor b. Cyanosis c. Supple to touch d. Uniform tone e. Purpura f. Even coloration

- Supple to touch - Uniform tone - Even coloration

Which of the following are accurate palpation techniques? a. Deep palpation is performed fist, then followed by light palp b. The presence of lumps or masses can be determined c. Tender areas are palpated first d. The surface of the fingers is used to determine the shape of an organ e. Palpation is not done over vascular structures f. Turgor can be determined g. Light palpation is depressing the tissue 2 or more inches down

- The presence of lumps or masses can be determined - The surface of fingers can help identify shapes of organs - Palpation is not done over vascular structures - Turgor can be determined

What is the order of the performance of these techniques for an abdominal assessment?

-Inspecion - Auscultation - Palpation - Percussion

Jaundice

A yellowing of the skin, mucous membranes, and eyes

During assessment of the thorax, the nurse documents expected findings: a. AP diameter is less than transverse diameter b. Quiet breathing c. Accessory muscles used for breathing d. Tactile fremitus present across chest e. Tripod posture observed f. Symmetrical lung excursion

AP diameter is less than transverse diameter (1:2) Quiet breathing Tactile fremitus present across chest Symmetrical lung excursion

Parethesia

Abnormal sensation such as burning, prickling, or tingling or numbness

A 21 yr old woman asks when she should perform a breast self-exam during the month. The nurse should inform the patient: a. "Any time you can think of it" b. "At the same time each month" c. "About halfway through each month" d. "Two to three days after your period"

About halfway through each month

What is included in the general survey?

Age, race, sex, gender orientation, appearance, affect and mood, substance use/abuse, weight, gait, speech, VS, safety concerns

Objective data can be gathered from the patient during which aspects of the physical assessment process? Select all that apply. a. Patient interview b. Health history c. General survey d. Physical examination e. Laboratory testing

All of them. Objective data consist of observed information or signs that can be collected during all stages of the physical assessment process. Even while the patient is answering questions, providing subjective data or symptom information, the nurse observes for physical signs of abnormalities or impairment.

Part of the neurological exam is evaluating the response of the cranial nerves. To test cranial nerve VIII, the nurse should: a. Ask the patient to read the printed material b. Assess the direction of the gaze c. Assess the patient's ability to hear the spoken word d. Ask the patient to say "ah"

Assess the patient's ability to hear the spoken word

Tortuosity

Bending & twisting

Bruit

Blowing, swooshing sound heard through a stethoscope when an artery is partially occluded

Eccymosis

Bruising ulceration, or permanent damage requiring skin grafting

How can a patient's long term memory be tested?

By asking them to repeat 3 words or numbers told to them earlier in the interview

A physical exam is to be performed by the nurse on a patient who has cardiopulmonary disease. Knowing this info about the patient, the nurse is alert when checking the nails for the presence of: a. clubbing b. paronychia c. Beau lines d. splinter hemorrhages

Clubbing

Ateclectasis

Collapse of all or part of lung

Vertigo

Condition of dizziness, "room spinning"

An inspection of lower extremities is being performed. The presence of arterial insufficiency is suspected when the nurse observes: a. increased hair growth b. cooler skin temperatures c. calf enlargement d. brown pigmentation

Cooler skin temps

The nurse is aware that which of the following are true regarding patients seeing their medical records? a. patients are unable to see their records without a court order b. family members are able to view the patients' records c. copies of the patients' records can be provided to the patient with a provider's release d. patient's should review the record in the presence of the primary care provider to ensure accuracy

Patients should review the record in the presence of the primary care provider to ensure accuracy

A peripheral pulse that is faint but detectable is documented by the nurse as:

Documented as 1. 0 - Absent (unable to palpate) 1 - Diminished 2 - Normal 3 - Bounding (can maybe even see pulsation)

A female patient is seen in the outpatient clinic for numerous cuts, bruises, and apparent burns. In a discussion with the patient, the nurse finds that the injuries are inconsistent with the stated cause. The patient also states that she is having trouble sleeping and she appears anxious. On the basis of these findings, the nurse suspects that the patient may be experiencing: a. substance abuse b. domestic violence c. vascular disease d. mental illness

Domestic violent

During a physical exam, a nurse should assess the temp of the patient's skin by using the: a. dorsal aspect of the hand b. pads of the fingers c. palmar surface of the hand d. fingertips

Dorsal aspect of the hand

Diplopia

Double vision

During the assessment of the nose and ears, the nurse documents unexpected findings: a. Erythema around the nares b. Small amount of cerumen c. Translucent, pearly gray eardrum d. Auricles aligned with the corner of the eyes e. Septum deviated from the midline f. Tragus sensitive to palpation

Erythema around the nares, small amount of cerumen, spetum deviated from midline, tragus sensitive to palpation

When teaching young women about reducing their risk of breast cancer, the nurse includes information about: (3)

Exercise Reducing alcohol intake Low fat diet w/ more fruits and veggies

Erythema

Redness of skin caused by congestion or dilation of the superficial blood vessels

During the assessment of the abdomen, the nurse documents expected findings: a. Visible protrusion by the umbiculus b. Flat abdomen c. Palpable firmness above the pubis symphysis d. Bowel sounds to all quadrants every 2-5 seconds e. Rebound tenderness to lower right side f. Borborygmi

Flat abdomen Bowel sounds to all quadrants every 2-5 seconds

The patient has an open wound on the skin. To perform the assessment what should the nurse obtain?

Gloves whenever there is a lesion

In the auscultation of the thorax, the nurse notes that the sounds heard over trachea are expected to be: a. soft, low pitched, and breezy b. harsh, loud, and high pitched c. moist, crackling, and bubbling d. medium pitched, intermittent, and grating

Harsh, loud, and high pitched

A student nurse is working with a patient who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. The student expects to hear: a. coarse crackles and bubbling b. high-pitched whistling sounds c. dry, grating noises d. loud, low-pitched rumbling

High pitched whistling sounds

During assessment of the musculoskeletal system, the nurse documents unexpected findings: a. Hypotonicity b. Full range of motion to upper extremities c. Muscles firm d. Clonus noted e. Symmetrical leg strength f. Slight muscle hypertrophy to dominant side

Hypertonicity Muscles firm Clonus noted

Identify community care and resources for public and home health services:

Immunizations, environmental surveillance medical equipment & medication delivery

How does the nurse assess for phlebitis in the lower extremities?

Inspect for redness, swelling, warmth, etc. Measure the calf as well.

During a physical exam, the patient tells the nurse that he has been told he has myopia. The nurse expects to find the patient is: a. nearsighted b. has decreased peripheral vision c. has diminished night vision d. experiences more glare, flashes, and floaters

Is nearsighted

The nurse asks a patient to explain the meaning of the phrase, "every cloud has a silver lining." This part of the exam is designed to assess: a. knowledge b. judgement c. association d. abstract thinking

Judgement

The nurse suspects that the patient may have vascular disease. During the exam, the nurse is alert to the patient's specific complaints of: a. diplopia, floaters, and headaches b. headache, dizziness, and tingling of body parts c. leg cramps, numbness of extremities, and edema d. pain and cramping in the toes after walking

Leg cramps, numbness of extremities, and edema

Describe the auscultation technique:

Listening to body sounds w/ or w/o stethoscope

The nurse is trying to auscultate heart and lung sounds but cannot hear clearly. What should the nurse do?

Make sure diaphragm/bell is contact with the skin, and ask the people in the room to quiet down with the surroundings also quieting down for the exam

During an inspection of the patient's skin, the nurse finds a brown, flat lesion with irregular borders. The nurse recognizes that this finding is associated with may be: a. melanoma b. squamous cell carcinoma c. basal cell carcinoma d. an area of old scar tissue

Melanoma

Identify three unexpected cardiac findings for an adult patient older than 30 years old:

Murmurs, thrills, s3 and s4 sounds, friction rubs, clicks, bruit over abdominal aorta, and pulse defecit

How are the carotid arteries assessed?

ONE AT A TIME - avoid compressing artery (can cause a fainting episode of patient)

Measurement of the patient's ability to sense the touch of a cotton ball on the forehead tests which cranial nerve? a. optic b. facial c. trigeminal d. oculomotor

Oculomoter

In preparing to conduct a physical examination on a patient, the nurse plans to: a. perform painful procedures at the end of the examination b. take long, detailed notes of all the findings during the examination c. keep the TV or radio on to distract the patient throughout the examination d. assess the dominant side of the body only during the examination

Perform painful procedures at the end of the exam

During the assessment of the female and male genitalia the nurse documents expected findings for a young adult: a. Perineal skin color slightly darker than surrounding skin b. Hemorrhoids c. Purulent drainage noted at urethral meatus d. Nodules noted on palpation of labia majora e. Smooth, pliable testes f. Coarse, thick pubic hair

Perineal skin color slightly darker than surrounding skin Smooth, pliable testes Coarse, thick pubic hair

Alopecia

Permanent or temporary hair loss where the scalp is clearly visible

What questions are asked to determine to patient's orientation and mental status? (P,P,T,S)

Person - what is your name? Place - where are you? Time - do you know what day, year, season it is? Situation - do you know what brought you here?

Changes to hair growth are usually indications of:

Poor nutrition, circulatory insufficiency, hormonal imbalance, chemotherapy, and overuse of dyes/rinses

Areas assessed in the head include:

Position of the head, tremors or tics, contour of the skull, presence of lesions or growths, positioning of the nose, ears, eyes, mouth, and shape/function of jaw

When PERRLA is documented it means:

Pupils Equal, Round Reactive to Light and Accomodation

During the neurological component of a physical exam, the nurse tests the function of the patient's cranial nerves. In testing cranial nerve 3, the nurse determines the patient's ability to: a. smile and frown b. move and tongue around c. identify sweet and sour tastes d. react to light with changes in pupil size

React to light with changes in pupil size

As part of the exam, the nurse will be assessing the patient's balance. The test that should be administered is the: a. Weber test b. Romberg test c. Allen test d. Rinne test

Romberg test

The nurse is examining a patient with dark skin. In assessing for jaundice, the nurse will specifically look at the: a. dorsal surface of the hands b. buccal mucosa c. ear lobe d. sclera

Sclera

The adolescent patient is found to have an S-shaped curvature of the spine. The nurse documents this finding as: a. lordosis b. kyphosis c. scoliosis d. stenosis

Scoliosis

Pruritis

Severe itching (ex: lice bites)

How does the nurse promote comfort for the patient during a physical examination/assessment? (3-5)

Should provide privacy, ensure comfortable room temperature, warm equipment, always position them comfortably, maintain relaxed atmosphere, & reduce/eliminate distractions

The nurse tests the accessory nerve function by asking the patient to: a. shrug the shoulders b. gaze downward c. detect odors d. blink

Shrug the shoulders

The nurse is auscultating the patient's lungs and notes normal vesicular sounds as: a. medium-pitched blowing sounds with inspiration equaling expiration b. loud, high-pitched, hollow sounds with expiration longer than inspiration c. soft, breezy, low-pitched sounds with longer inspiration d. sounds created by air moving through small bronchial airways

Soft, breezy, low-pitched sounds with longer inspiration

A nurse is evaluating a patient for conduction deafness in the right ear. In using the Weber test, the nurse appropriately places the tuning fork and conforms this type of deafness when: a. sound is not heard in either ear b. sound is heard best by the patient in the left ear c. sound is heard best by the patient in the right ear d. sound is reduced and heard longer through air conduction

Sound is heard best by the patient in the right ear

During the physical exam, the patient starts to experience respiratory distress. The nurse should:

Stop exam immediately Sit them up Use oxygen if available Call for help

What are the first clinical signs of osteoporosis?

Sudden and severe loss of height accompanied by back pain

What are the preventive strategies that the nurse can teach the patient in relation to cataracts: (3)

Sunglasses + hat while outside Quit smoking + limit alcohol consumption Increased intake of vitamin E & B

Edema

Swelling when there is a buildup of fluid in underlying tissues

Describe the percussion technique:

Technique used by tapping parts of the body to produce vibration

What safety measure needs to be taken when administering a Romberg test?

Tell patient to open eyes if they feel off balance and also spot them just in case

The nurse notes that the patient's pupils are less than 2 mm in size and do not dilate. What does the nurse suspect?

That the patient ingested an opioid or a medication for glaucoma

To maintain asepsis during a female genital examination, the nurse should: (2)

Wear gloves Work from back to front

Which action by the nurse would be most effective in determining whether a patient has muscle hypertonicity? a. Watching the patient walk to the bathroom b. Asking the patient to squeeze both hands of the nurse c. Performing passive ROM exercises with the patient d. Checking the patient's spine for the presence of postural irregularities

c. Perform passive ROM exercises with the patient Performing passive range of motion allows the nurse to assess the patient's level of resistance to movement for an abnormal increase in muscle tone. Watching the patient walk provides information on steadiness of gait and posture; asking the patient to squeeze the nurse's hands assesses muscle strength, rather than tone; and checking the patient's spine for irregularities assesses for kyphosis or lordosis.

How is the Allen test performed and what is the purpose of this test?

Used in medical examination of arterial blood flow to the hands. Make a fist. Hold for 30 seconds. Hold radial and ulnar arteries for a few seconds. Let go and color should return in a few seconds.

Describe the palpation technique:

Uses parts of hand to touch and feel for various characteristics (temp, moisture, turgor, tenderness + thickness)

For the assessment of the eyes, identify the expected findings: a. Strabismus b. Ptosis c. Hordeolum d. Periorbital edema e. Xanthelasma f. Transparent, glossy cornea

Transparent, glossy corneas

To test fine motor skills, the nurse will ask the patient to: a. walk b. stand on one foot c. bend over and touch the toes d. turn pages one at a time

Turn pages one at a time

Which action by a patient with a family history of macular degeneration would demonstrate use of a prevention strategy that has been found to help prevent deterioration of the macula? a. Using medicated eyedrops b. Avoiding the use of sunglasses c. Taking vitamin b6 and b12 supplements d. Minimizing dietary intake of antioxidants

c. Taking vitamin b6 and b12 supplements Taking dietary supplements, including vitamins E, C, B6, B12, beta carotene, zinc oxide, and copper, has been found to limit the development and severity of macular degeneration. Wearing sunglasses outside is another important recommended prevention strategy. Using medicated eyedrops and avoiding dietary antioxidants are not indicated in the prevention of macular deterioration.

During assessment of the mouth, throat, and neck, the nurse documents unexpected findings: a. Oral membranes pale-pink b. Able to clench teeth and smile c. White patches on pharynx d. Nonpalpable lymph nodes e. Distended jugular veins at 45 degrees f. Cheilitis

White patches on pharynx, Distended jugular veins at 45 degrees, cheilitis

What should the nurse do to maintain asepsis and promote infection control before and during the physical assessment?

Wipe down the exam table and equipment with antiseptic bacterial agent, including the stethoscope. Hand-washing and use of clean gloves also aids in the reduction of bacterial spread.

Cerumen

Yellow waxy material that lubricates and protects the ear canal

Which assessment finding would be most important to document in a patient with known liver disease who has a distended, taut abdomen? a. Abdominal girth b. Dentition condition c. Benign cardiac murmurs d. Daily ambulatory distance

a. Abdominal girth Increasing abdominal girth may be due to ascites, which is potentially life threatening and could cause respiratory arrest if the ascitic fluid is not drained. Dentition condition and benign murmurs are not directly associated with liver disease. The patient's condition may affect ambulatory distance; however, it is not the most important assessment finding listed.

A nurse is preparing to auscultate a patient's chest. In which area should the nurse listen to evaluate the patient's aortic valve? a. Second right intercostal space b. Third left intercostal space c. Fifth right intercostal space d. Fifth left intercostal space along the midclavicular line

a. Second right intercostal space The second intercostal space on the right is the auscultation point for the aortic valve. The ventricles and pulmonic valve are located on the left. The point of maximal impulse (PMI) over the mitral valve is located between the left fourth and fifth intercostal spaces.

The nurse begins the assessment of patient breath sounds and notes diminished breath sounds at the base of the right lung. What action should the nurse take next? a. Refer the patient for a chest x-ray b. Listen to the base of the patient's left lung c. Notify the patient's PCP d. Palpate the patient's lung fields bilaterally

b. Listen to the base of the patient's left lung When auscultating a patient's lungs, the nurse should follow a pattern that compares lung fields side to side in each area, making listening to the base of the patient's left lung the next step for this nurse to take. Referring the patient for an x-ray, palpating the patient's lung fields, and notifying the patient's physician might be indicated later, depending on the outcome of the full respiratory assessment.

During examination of a patient's neck with the bell of the stethoscope, the nurse identifies a carotid bruit. When are bruits audible in the neck? a. When jugular vein distention is present b. During normal examination of the neck c. When the carotid artery is partially occluded d. With complete occlusion of both carotid arteries

c. When the carotid artery is partially occluded A bruit indicates blood flow turbulence and occurs with partial occlusion of a carotid artery by atherosclerosis. Bruits are not associated with jugular vein distention and are an abnormal assessment finding. Bruits will not be heard if the artery is 100% occluded or if the artery blood flow is normal, without partial obstruction.

Which sequence best identifies the order in which the nurse should complete an abdominal assessment? a. Inspection, palpation, percussion, auscultation b. Auscultation, inspection, palpation, percussion c. Auscultation, palpation, percussion, inspection d. Inspection, auscultation, palpation, percussion

d. Inspection, auscultation, palpation, percussion Assessment of the abdominal cavity requires auscultation to immediately follow inspection, before palpation or percussion, to avoid stimulating the bowel and eliciting inaccurate assessment results.

The nurse notes the presence of ptosis when assessing an adult patient's eyes. Which potential cause would be considered of most concern, requiring further evaluation as soon as possible? a. Loss of skin elasticity b. Levator muscle weakness c. Congenital ocular abnormality d. Oculomotor cranial nerve 3 paralysis

d. Oculomotor cranial nerve 3 paralysis Oculomotor nerve paralysis may indicate the presence of a larger neurologic problem that requires further investigation as soon as possible. Loss of skin elasticity and muscle weakness may be due to aging, and congenital ptosis does not require immediate attention in an adult.

What actions should the nurse take to assess whether a patient with a left above-the-knee amputation has adequate lower extremity circulation to the stump? Select all that apply. a. Palpate the stump for warmth b. Assess the pedal pulses bilaterally c. Evaluate the left popliteal pulse rate d. Inspect the stump and right leg for color e. Check the left femoral pulse for strength

palpate stump for warmth, inspect the stump and right leg for color, and check the left femoral pulse for strength Palpating the stump for warmth and observing the stump and right leg for color will help evaluate the effectiveness of the patient's circulation in the left leg. Comparing the appearance of one limb with that of its counterpart is an essential part of assessment. Assessing the patient's left femoral pulse is critical because it is the closest peripheral pulse to the site of the amputation. The patient has only right popliteal and pedal pulses as a result of the left above-the-knee amputation, making bilateral popliteal and pedal pulse assessment impossible.

The expected appearance of the oral mucosa in a light-skinned adult is: a. pinkish-red, smooth, moist b. light pink, rough, and dry c. cyanotic, with rough nodules d. deep red, with rough edges

pinkish red, smooth and moist

Describe the inspection technique:

uses senses (vision/smell) to observe and detect any normal/abnormal findings; used from the moment you meet the client and continues throughout examinations