Nursing - Physical Assessment

Start Studying!

Terms

undefined, object

copy deck

What type of lesions would you describe a first degree burn, petechiae, or purpura?: Macules; a flat, localized lesion that shows as a change in skin color
When assessing your patient's bones and muscles, which of the four assessment techniques could you use?: Inspection, Palpation, Percussion
What sound would you hear with emphzyma?: booming, hyper-resonance sound
In explaining your assessment to the patient, what are three things to do?: > Make the patient comfortable
> Provide privacy for them
> Answer any ? they may have
What term is used to describe a decrease in O2, leading to blueness in the lips and nail beds?: Cyanosis
When assessing your patient's abdomen, which of the four assessment techniques would you use?: Inspection, then Auscultation, then Palpation, then Percussion - hear before you feel on this one!
What is an example of tympany?: Percussing the belly / abdomen; sound comes from gas in the abdomen
In visually assessing a patient's eyes, ears, and nose, what are several things you should look for?: Assess moisture, color, texture, shape, position, size, color, symmetry
When you see a patient that has acne or furnuncles, you know that they have ____________.: Pustules, a vesicle or bullae filled with exudate
When assessing your patient's eyes, ears, nose, which of the four assessment techniques could you use?: Inspection, Palpation
What four qualities of sound do you look for when auscultating the body?: Pitch, Intensity, Duration, and Quality
True or False: When doing palpation, be sure to use the whole palm of each hand to cover more surface area.: FALSE! Use the pads of your fingers
When a patient has an allergy to the hospital sheets, what term would you use to describe their rash on their back and posterior legs?: Erythema
When assessing your patient's chest and back, which of the four assessment techinques would you use?: Inspection, Palpation, Percussion, Auscultation
Now, what are two other parts of the general survey/assessment ?!: The patient's general appearance and behavior
When doing a head to toe physical assessment, what four things will you do with each patient and on each body system of the patient?: Inspection, Palpation, Percussion, Auscultation
What percussing over a bone, you should hear what?: flatness due to the dense tissue
What is the Point of Maximal Impulse ?: The Apex / the point at which the ventricles are closest to the chest wall - easiest location to hear the (apical) pulse
What form do you use with light palpation?: Always do light palpation first
Go gently in a circle so that the skin is slightly depresssed
What are the purposes of the physical assessment?: It provides baseline data for the nursing dx and POC
It supplements, confirms, or refutes information from the nursing hx
It helps to make clinical judgments on the pt's health status
It is used to evaluate the health care and progress of the patient
-It is systemmatic and efficient
What term would you use to describe a patient's skin when the patient's urine is orange colored in the catheter, they also have a liver problem, and their eyes may also be yellow?: Jaundice
When assessing the skin, which of the four assessment techniques could you use ?: Inspection, Palpation
When percussing the heart, liver, spleen, what sound would be normal to hear?: dullness - the tissue is denser than bone
Atrium is to __________ of the heart as Ventricle is to Apex of the Heart: Base of the heart
True or False: Using one hand to apply pressure and the other hand to feel sensations is the process of deep palpation.: TRUE !!
When assessing your patient's urinary system, which of the four assessment techniques could you use?: Inspection, Palpation
What is the FIRST part of the Head -> Toe Assessment?: V I T A L S I G N S ! ! !
When assessing your patient's BLEs, which of the four assessment techniques could you use?: Inspection, Palpation
If a patient said that they got stung by a bee just before they came to see you at HealthReach, you would expect to find a lesion looking like ...?: A wheal; an elevated, circumscribed transient lesion
If you don't hear any breath sounds, what might this be a sign of?: a PE, blockage, or a collapsed lung - look for additional S/S !
If you pinched the forehead of your patient, moved your fingers and the skin stayed in or close to the pinched position, you could say that they were __________? You would assess them as having decreased _________?: Dehydrated; [decreased] skin turgor
Define receptive aphasia.: The loss of the ability to comprehend spoken or written words
If a patient's chart says that they currently have Psoriasis, you would expect to find what kind of lesions on them?: Papules, plaques, nodules (solid, elevated, varying in size)
Define expressive aphasia.: The loss of the ability to express one self.
True or False: When doing light and deep palpation, you should do the palpate the tender areas first to identify the critical areas of your assessment.: FALSE ! Deeply palpate the tender areas last - and don't do it on patients with abdominal pain!
Which of the breath sounds duplicate a "blowing" sound and has equal inspiratory and expiratory phases?: Bronchiovesicular
Describe pallor.: Lack of color; paleness due to Inadequate circulation, due to decreased oxygenation, also may be seen with a dec. Hct. (Hematocrit)
Vesicular is to best heard at the base of the lungs as Bronchiovesicular is to .......: best heard between the scapulae and lateral to the sternum at the first and second intercostal spaces
True or False: Of hair, skin, and nails, nails are the first line of defense against injury since they are used for feeling.: FALSE !! Skin is the first line of defense.
Which of the breath sounds is created by air passing through the smaller airways (bronchioles and alveoli) ?: Vesicular
When using palpation, what can you assess on the patient?: texture, temperature, vibration, position, size, motility of organs, masses, distention, pulsation, and pain upon pressure
S1 is to the closing of the AV valves as S2 is to ...: closing of semi-lunar valves
If you see a lesion on a patient that was a clear, fluid-filled pocket between two skin layers, you would document it as a _______________.: Vesicle or bullae, such as a second degree burn
Define resting tremor.: a tremor that occurs constantly, without movement of the extremity.
Name two types of percussion and give an example of each.: Direct - striking the forehead or paranasal area
Indirect - stiking the lungs or abdomen
Define intentional tremor.: a tremor that occurs only with movement of the affected extremity.
Name two types of tremors.: Intentional and resting
Crackles and Friction Rub are similiar in that they ....: Won't clear by coughing
What might be the cause of hypo- and hyper-active bowels sounds ?: constipation and diarrhea, respectively.
When assessing urine output, what would you look for?: look at the color of urine in the catheter bag or briefs, assess smell and sediment
What is PVR / Post Void Residual ?: the condition of urine left in the bladder, evidenced by urine dribbling and decreased uring output.
What color should the average person's urine be ?: clear and yellow
Define Bronchiovesicular breath sounds in terms of intensity and pitch.: Moderate intensity and moderate pitch
What is a complication of surgery that results in the paralyzing of the bowels?: An ileus
If your patient's urine was amber in color, what might be the cause?: They are dehydrated
When assessing the bowel sounds, in what order do you perform the steps?: Inspection, Auscultation, then percussion and palpation - you want to listen before you touch, to assess more accurate sounds
Of the four abnormal breath sounds, which is best heard on expiration ?: Wheezes
In the past, why were peanuts listed on the Plain M&Ms ingredient list?: They were used for the candy coating ! ;-)
True or False: Rales and Rhonchi are normal breath sounds, heard at the bases of the lungs, while Gurgles and Crackles are abnormal or adventitious sounds, heard in narrowed passage ways.: FALSE ! All four are adventitious sounds which are abnormal breath sounds.
What would you inspect, palpate and ausculate in assessing the peripheral vascular system?: bilateral carotid arteries
True or False: The carotid veins are the only blood supply from the heart to the brain.: FALSE ! The carotid ARTERIES are th only blood supply to the brain.
"Dubb" is to aortic and pulmonic valves as "Lubb" is to ...: mitral and tricuspid valves
In assessing the peripherial vascular system, you would measure _________ and palpate the __________ .: BP, peripheral pulses
Name four adventitious breath sounds.: Crackles, Gurgles or Rhonchi, Friction Rub, and Wheezes
Which of the breath sounds is heard anteriorly over the trachea and is louder than vesicular sounds?: Bronchial
When assessing blood supply in BLEs, what pulses do you palpate?: Posterior Tibial Pulse and Dorsal Pedal Pulse
Which of the breath sounds is created in the bronchi by air passing through ?: Bronchiovesicular
If you recognize that your patient's LE is void of hair, what might this be a cause of?: Decreased circulation
True or False: The carotid arteries and the radial arteries are the only two locations to beat in synch with the heart since they are the closest to the heart: FALSE ! Only the carotid arteries beat in synch with the heart
Which of the breath sounds is soft in intensity and low in pitch?: Vesicular
During report, you learn that your patient has a bruit on their L carotid artery. During ausculation of this artery, you should hear...: a blowing or swishing sound-sounds like a clogged drain, caused by turbulence due to a narrowing of the lumen or increased cardiac output; this is abnormal!
If you listen to your patient's breath sounds and their chest sounds like it is continuously snoring, you most likely are hearing __________ .: Gurgles or Rhonchi
What portion of heart sounds are called diastole?: S2 -> next S1
Crackles and Rales are most commonly heard where ?: at the bases of the lower lung lobes
Bronchial breath sounds is to short inspiration and long expiration as _______ breath sounds is to long inspiration and short expiration.: Vesicular - ~ 2.5 times as long of inspiration v. expiration
Gurgles and Rhonchi are to low-pitch as Wheezes are to __________ .: high-pitch
When listening to your patient, you hear a continuous, low pitch, gurgling sound over the bronchi; you ask them to cough, then you longer hear the sound. You most likely heard _________.: Gurgles or Rhonchi
True or False: S1 refers to closure of the mitral and tricuspid valves.: TRUE !
Jugular vein distention could be a sign of ?: R sided heart failure - the atrium not allowing blood to flow freely to the heart
True or False: When the semi-lunar valves close, this stage is referred to as S2.: TRUE !
What portion of heart sounds are called systole?: S1 -> S2
In palpating your patient's bruit, you would feel...: a vibrating sensation like the purring of a cat or H2O running through a hose, this is called a "thrill"
Which of the abnormal breath sounds is air passing through narrowed airways as a result of secretions, tumors, and swelling and can be heard over all lung fields but primarily over the trachea and bronchi?: Gurgles and Rhonchi
What would you inspect only when assessing the peripheral vascular system?: the jugular and peripheral veins and skin and tissues to determine perfusion.
4 is to abdominal quadrants as 9 is to _______.: is to regions
When subdividing the abdomen into four quadrants, what body part acts as the vertex?: The belly button / umbilicus
Which of the abnormal breath sounds is air passing through constricted airways as a result of secretions, tumors, and swelling and can be heard over all lung fields?: Wheezes
What abnormal sound is a superficial grating or creaking sound heard during inspiration or expiration ?: Friction Rub
You are listening to your patient's breath sounds at their lung bases. You hear fine, short, interrupted, crackling sounds that are high in pitch when your patient both breathes in and out. After coughing, you still hear the sound. Most likely you are he: Crackles or Rales
Which of the adventitious breath sounds is the result of inflamed pluera rubbing together ?: Friction Rub
Which of the breath sounds is a high-pitch, loud "harsh" sound created by air passing through the trachea?: Bronchial
Which of the breath sounds is a high-pitch, loud "harsh" sound created by air passing through the trachea?: Bronchial

Start Studying!

Deck Info

Number of cards 92