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Nursing Test 2

Nursing Test 2 Questions

QuestionAnswer
What are the skills used in a physical examination? Inspection, Palpation, Percussion, Auscultation, Olfaction
What do you assess with inspection? Gait, personal hygiene, affect, and behavior
What supplies can you use for inspection? Otoscope, ophthalmoscope, and penlight
What do you need to inspect? You need adequate lighting, proper positioning,
What do you assess with palpation? Temperature, skin texture, moisture, anatomical landmarks, abnormalities as edema, masses, areas of tenderness
What different parts of the hand do you use for palpation? Fingertips, dorsum of hand, palmar surface of hand, grasping with fingers and thumb.
When palpating what do you use your fingertips for? Fine tactile discrimination of skin texture, swelling, specific locations of pulsations and masses
When palpating what do you use the dorsum of your hand for? Temperature determination
When palpating what do you use the palmar surface of the hand for? For locating general area of pulsations.
When palpating what do you use "grasping with fingers and thumb"? To detect the position, shape, and consistency of a mass.
What is percussion? Tapping your fingers on the skin using short strokes.
What does tapping produce? Vibrations and the resulting sound allows you to determine location, size, and density of underlying structures.
Percussion is helpful when assessing what body parts? The lungs and abdomen.
What is direct percussion? Tap lightly with the pads of the fingers directly on the skin.
What is indirect percussion? It requires two hands. It is used more frequently.
What is direct auscultation? Listening without using an instrument.
What is indirect auscultation? Listening with the help of a stethoscope.
What do you use the diaphragm of the stethoscope to listen to? High pitched sounds that normally occur in the heart, lungs and abdomen.
What do you use the bell of the stethoscope to listen to? Low pitched sounds such as extra heart sounds (murmurs) or turbulent blood flow, known as bruits.
What is the rationale for using olfaction? Fruity or acetone smelling breath would lead you to think the patient has ketoacidosis (which may accompany diabetes).
What are the adaptations when examining a infant? Allow the parent to hold the infant on their lap otherwise position the infant on a padded examination table.
What are the adaptations when examining a toddler? Perform invasive procedures last. Allow the toddler to sit on parent's lap. Allow choices. Allow the child to show developmental skills. Use praise.
What are the adaptations when examining a preschooler? Demonstrate procedure on a doll. Let the child help. Give reassurance as you go through the exam, for example, "Your lungs sound very healthy".
What are the adaptations when examining school-age children? Develop rapport by asking about their favorite school. Allow independence - undress themselves and get up and down from the table by themselves. Demonstrate your equipment before you use it.
What are the adaptations when examining adolescents? No parent or sibling present, respect privacy during exam, emphasize healthy lifestyle habits, and assess for suicide potential.
What are the adaptations when examining young and middle age adults? No specific modifications unless acute/chronic disease or cannot understand and follow instructions.
What are the adaptations when examining older adults? Taylor exam to energy and mobility levels. Adapt techniques for vision and hearing changes.
What is the acronym SPICES? It helps you remember common problems of the elderly such as Sleep disorders, Problems with eating and feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown.
Identify the components of a general survey. Appearance and behavior, body type and posture, speech, dress, grooming, and hygiene, mental state, vital signs, height and weight.
What might a slumped position indicate? Fatigue, depression, osteoporosis, or pain.
What might a unsteady gait indicate? Associated with joint, muscle, or neurological disorders.
Inappropriate or illogical responses may be associated with what? Psychiatric disorders.
Difficulty speaking or changes in voice quality may indicate what? A neurological problem
Rapid speech may be a sign of what? Anxiety, hyperactivity or use of stimulants.
Hoarseness could indicate what? Inflammation in the throat from infection, overuse, a foreign body, or perhaps a tumor or other obstructive material.
Slow speech may be due to what? Depression, sedation from medications, or neurological disorders.
Vocabulary and sentence structure provide information about what? The clients educational level and comfort with the language.
A foreign accent with hesitancy and/or sparse verbalization may signal what? A language barrier and a need for an interpreter.
An unkempt appearance may reflect what? Chronic pain, fatigue, depression, or low self-esteem.
Poor hygiene may indicate what? A self care deficit or physical or mental origin, or lack of easily accessible bathroom facilities.
To evaluate mental status what should you do? Notice whether the client seems awake, alert, and oriented to time, place, person, and self.
Bizarre responses may signal what? A psychiatric problem.
Lethargy may be due to what? Medications, depression, or a neurological, thyroid, liver, kidney, or cardiovascular disorder.
Confusion and irritability may indicate what? Hypoxia or medication side effects.
Inability to provide a health history or to recall information may indicate what? A neurological disorder.
Why is height and weight important? This data is used for proper dosing medications.
Who is BMI calculation not useful for? Athletes, pregnant women, growing children, or for frail and sedentary older adults.
Created by: 1SmartLady