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Unit 4 Exam PA
Physical Assessment
| Question | Answer |
|---|---|
| What are the two parts of an Admission Assessment? | Nursing History Physical Assessment |
| The Nursing History provides what type of data? | Subjective data |
| The Physical Assessment provides what type of data? | Objective Data |
| What are the 5 dimensions of the client that a comprehensive health assessment encompasses? | Physiological, psychological, sociocultural, spiritual, and developmental. |
| Why is it important to perform a thorough Admission Assessment? | All further assessments will be compared to it to determine improvement. (Baseline info) |
| What are the 4 purposes of a Physical Assessment? | 1. ID Pt's healthcare needs 2. Determine priority of care and expected outcomes. 3. Establish a Nursing Care Plan. 4. Communicate the Pt's health status. |
| How soon after the Pt has been admitted should a Physical Assessment be performed? | Within 24 hours |
| What involves the use of all senses but taste to obtain info about the structure and function of an area of the body that is beig observed or manipulated? | Physical Exam/ Physical Assessment |
| Which part of the stethoscope detects low pitched sounds? | The bell |
| What types of sounds can be heard with the bell of a stethoscope? | heart murmurs, bruits, abnormal heart sounds |
| What types of sounds can be heard with the diaphragm of the stethoscope? | breath sounds, normal heart sounds and bowel sounds |
| What part of the stethoscope detects high pitched sounds? | The diaphragm |
| What is an ultrasonic device that detects blood flow through a vessel? | A doppler. |
| When should a doppler be used? | When a pulse cannot be palpated. |
| What are the 4 Assessment techniques? | Inspection, palpation, percussion, auscultation |
| What is the systematic and deliberate visual observation used to determine health status? | Inspection |
| When during the physical assessment should the nurse use inspection? | Throughout the entire assessment. |
| What 6 things can palpation determine? | position, size, fluid, mass, vibration, temperature |
| What parts of the nurse's body should be used for palpation? | palmar surfaces of the fingers and pads, ulnar surfaces of the hands and fingers, and the dorsal surfaces of the hands(temperature) |
| How much force should the nurse exert when palpating a patient? | Use light touch first, then palpate deeper unless Pt expresses pain |
| Which assessment technique is used to determine if organs or tissues are swollen, edemic or necrotic? | Percussion |
| What type of sounds are heard when a nurse percusses over air? | loud sounds |
| What causes soft sounds to be heard while using percusson? | Percussing over solids |
| Where on the body is percussion most usually used? | Over lungs and abdomen |
| When during a physical assessment should auscultation always be performed? | Last, except with abdominal sounds, where it is done first. |
| What happens if the nurse auscultates the bowel sounds after palpating or percussing? | The bowel is stimulated and the sounds heard will be in reaction to that, not normal bowel sounds. |
| What terms should be used to describe sounds heard when auscultating? | duration, pitch, intensity, quality, location |
| What are some examples of words used to describe duration? | long, short, continuous, interrupted |
| What are some examples of words used to describe quality? | whistling, gurgling, snapping, rubbing |
| When should vital signs be checked: before, during, or after a physical assessment? | Before |
| At what degree should the HOB be raised to to check for JVD? | 45 degrees |
| What is JVD? | Jugular Vein Distention |
| What causes JVD? | Fluid overload causes jugular vein to pulsate and bulge. |
| What is JVD a sign of? | Pulmonary hypertension and/or congenitive heart disease/failure |
| What is considered "sluggish" in regards to capillary refill? | More than 3 seconds |
| What are terms used to describe skin color? | pink, pale, cyanotic, grey, mottled |
| What are terms used to describe skin temperature? | Cold, cool, hot, warm, feverish |
| When pulses are palpated, which ones are counted and which ones are graded? | Apical and radial counted, others graded. |
| What doess a pulse grade of 0 mean? | Absent |
| What does a pulse grade of 1+ mean? | Barely palpable, difficult to feel |
| What does a pulse grade of 2+ mean? | "Normal", detected readily, obliterated by strong pressure |
| What does a pulse grade of 3+ mean? | Bounding, easy to find, difficult to obliterate |
| What is tissue that has extra interstital fluid? | Edema |
| When edema leaves an indention when pressed and the finger is pulled away it is said to be what kind of edema? | Pitting edema |
| What is a 1+ on the Edema scale? | Barely detectable, less than or equal to 2 mm |
| What is a 2+ on the Edema scale? | Indentation of more than 2 mm but less than or equal to 5 mm |
| What is a 3+ on the Edema scale? | Indentation of more than 5 mm to 10 mm |
| What is a 4+ on the Edema scale? | Inentation of more than 10 mm |
| Which heart sound is heard when the mitral and tricuspid valves close? | S1 |
| Which heart sound is heard when the aortic and the pulmonic valves close? | S2 |
| Which heart sounds can be heard at all auscultation sites? | S1 and S2 |
| What are the sounds of abnormal blood flow caused by valves not closing properly? | Murmurs |
| What is caused when heart valves do not close properly due to stenosis? | Valvular regurgitation |
| Which heart sound is commonly referred to as "lub"? | S1 |
| Which heart sound is commonly referred to as "dub"? | S2 |
| Which abnormal heart sound occurs because the left ventricle doesn't work properly? | S4 |
| Which abnormal heart sound is a common sign of congestive heart failure? | S3 |
| What is air trapped in subcutaneous tissue called? | Crepitus |
| What is a high pitched sound caused by the narrowing of bronchi that is usually heard on expiration? | Wheezing |
| What is a rumbling or gurgling sound heard during expiration called? | Rhonchi |
| What high pitched breath sounds sound like hair rubbing together? | Crackles/rails |
| Which lung sounds are caused by secretions sitting in the upper lungs? | Rhonchi |
| Which lung sounds are scratchy and high pitched? | Rub |
| Which lung sounds are caused by fluid in the alveoli of the lower lung? | Crackles |
| What are the four quadrants of the abdomen? | RLQ, RUQ, LUQ, LLQ |
| How should a client be positioned for an abdominal assessment? | Flat on back with knees slightly bent and arms at sides. |
| How many sites should be auscultated during the abdominal assessment? | 2 areas per quad, 8 total |
| Why should you measure the girth of a patient around the umbilicus? | To check for distention |
| How would you describe bowel sounds that are heard every 5 - 10 seconds? | Active/Normal |
| How would you describe bowel sounds that are heard less than 5 seconds apart? | Hyperactive |
| How would you describe sounds heard over the bowel that occur more than 15 seconds apart? | Hypoactive |
| How would you describe bowel sounds where no sounds are heard for a full 5 minutes over all quads? | Absent |
| What is the "boom" like sound heard when purcussing over a cavity with air in it? | Tympany |
| Where is tympany considered normal to be heard? | Over the stomach |
| Where should tympany never be heard? | Over the intestines |
| what kind of sound is normally heard over fluid or fecal masses? | A dullness |
| Why should be done to confirm whether tymphany in intestines is gas or free air? | X-RAY |
| What causes white patches on oral mucosa? | Thrush (yeast) |
| What does it mean to be oriented X 4? | Oriented to person, place, time and situation |
| Upon entering patient room, the nurse should attempt to get the patient's attention by what means first? | Verbally |
| Upon entering patient room, the nurse should attempt to get the patient's attention by what means second? | Light touch |
| Upon entering patient room, the nurse should attempt to get the patient's attention by what means as a last resort? | Painful, noxious stimuli |
| How long does it take for IV pain medication to take effect? | 5-15 minutes |
| How long does it take for oral pain medication to take effect? | Up to an hour |
| What is the name of the medication that can reverse an overdose, be it accidental or intentional? | NARCAN |
| What does PERRLA stand for? | Pupils Equally Round and Reactive to Light and Accomodation |
| When checking pupils for their reactivity to light, what is the term for when you shine the light into one pupil and the other reacts spontaneously? | Consensual pupillary reaction |
| When eyes are focused on something in the the distance, will the pupils be dilated or constricted? | Dilated |
| What is the term for when pupils constrict to better see something close up? | Accomodation |
| How do you check Homan's sign? | Support calf and force dorsifelexion |
| What happens if a sharp pain is felt in the calf when checking for the Homan's sign? | Most likely a clot or a DVT |
| Which problem below has the greatest potential for precipitating hyperkalemia? Diaphoresis, vomiting, diarrhea, burns | Burns. during the first 24 hours after a burn, K is elevated in the blood stream because of the destruction of tissue and oliguria. |
| A Pt's BP is 140/90 mm HG. The Pt's pulse pressure is: | 140-90=50 |
| Which is most likely found while assessing an older adult? An increase in: Nail growth, skin elasticity, urine residual, or nerve conduction? | Urine residual |
| Which assessment technique is the most informative concerning a pt's respiratory status? | Auscultation |
| Why should a nurse wait 2 minutes after taking a PT's BP to take it again? | Allows for venous return and prevents falsely elevated results. |
| How long after a PT drinks icewater should a nurse wait to obtain the PT's oral temperature? | 15 minutes |
| The normal range for respirations is how many breaths per minute? | 14-20 |
Created by:
cestes1001
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