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PhysicalAssessment
Kaplan Physical Assessment
| Question | Answer |
|---|---|
| gurgling sounds commonly heard on inspiration | rales |
| squeaky sounds heard during inspiration and expiration | wheezes |
| grating sound or vibration heard during inspiration and expiration | pleural friction rub- caused by an inflamed pleura; does not clear by coughing |
| loud transmission of voice sounds caused by consolidation of lung | bronchophony |
| reflex within the body;to access ______, the extremity should be relaxed & partially stretched, compare responses on the right & left side of the body, responses should be equal, graded on a 4pt. scale w/ 1+ being diminished and 4+ being hyperactive | deep tendon reflexes |
| what are two reinforcement techniques for the upper extremities? | 1) clenching of teeth 2) contraction of quad muscles |
| what is a reinforcement technique for the lower extremities? | interlocking of fingers and trying to pull them apart |
| reflex responses of 0+ may occur when... | a component of the lower motor neurons or reflex arc is impaired |
| reflex responses of 4+ may occur when... | lesions of the upper motor neurons or impairment of the higher cortical levels |
| the difference between systolic and diastolic BP readings; serves as an indirect measure of cardiac output | pulse pressure |
| what is a normal difference for pulse pressure? | 30-40mmHg |
| what are some things that a lowered pulse pressure could indicate? | 1) hypervolemia 2) heart failure 3) shock 4) mitral stenosis |
| what are some things that a widened or increased pulse pressure can indicate? | 1) slow heart rate 2) atherosclerosis 3) hypertension |
| the difference between apical and radial pulse is called a _____; may reflect dysrrhythmia | pulse deficit |
| the stroke volume multiplied by the heart rate is called ______. | cardiac output |
| ____ is the amount of blood ejected with each heartbeat | stroke volume |
| ____ is the number of beats per minute | heart rate |
| _____ is the product of cardiac output and peripheral resistance | blood pressure |
| pulse pressure reflects what 3 things? | 1)stroke volume 2)ejection velocity 3)systemic vascular resistance |
| when assessing a pt for tactile fremitus, which part of the hand should the nurse use? | ulnar and palmar surface of the hand |
| the ______ is used for assessing temp since the skin is thin and there is nerve density | dorsum (back of hand) |
| _____ are used for palpating pulses, lymph nodes, texture, consistency, size, shape, crepitus (all areas requiring fine discrimiation | fingertips and fingerpads |
| ___ is the temulous vibration, palpable over the posterior wall of the chest, which is produced when a patient says "99" | tactile fremitus |
| ___ are sensitive to vibrations and thrills. | ulnar and palmar surfaces |
| tactile fremitus will be __ when lung consolidation exists, such as pneumonia and ___ when pleural effusion, pneumothorax, bronchial obstruction and air-trapping occurs | increased/ decreased |
| if a person's visual activity is tested with a Snellen chart and reported to be 20/60, the nurse knows that the number 60 indicates which of the following | the distance at which a person with normal vision can read the chart |
| the involuntary drifting of one eye out of alignment with the other eye ("lazy eye") | Strabismus |
| abnormal, involuntary, rapid oscillating eye movements; may be horizontal, vertical, rotany, or mixed in direction | nystagmus |
| ___ is light intolerance, seen in various conjunctival disorders and conditions such as rubeola (measles), rubella (german measles), encephalitis | photophobia |
| ___ is drooping of the upper eyelid; may be congenital or aquired weakness or paralysis | ptosis |
| when performing a physical assessment, the home health nurse notes that the eyes of the pt involuntarily move rapidly from side to side. what should the nurse chart? | nystagmus |
| what is the normal range for pH of urine? | 4.5-8. tends to be primarily acidic; helps protect bacterial infection |
| what is the normal BP for a 5-12 year old? | 100-110/56-60mmHg |
| what is the normal respiratory rate for an adult? | 12-20 per minute |
| what is the normal pulse rate of an adult | 60-100bpm |
| what is the normal BP for an adult? | <120/80 mmHg |
| what is the normal body temperature when taken orally? | 98.6/37.0 |
| what is the normal body tem when taken rectally? | 99.6/37.6 |
| what is the normal body temp when taken using the axillary method? | 97.6/36.5 |
| breahting accomplished by abdominal muscles and diaphram; may be used to increase effectiveness of ventilatory process in certain conditions | abdominal respirations |
| temporary cessation of breathing | apnea |
| periodic breathing characterized by rhythmic waxing and waning of the depth of respirations | cheyne-stokes respirations |
| difficult, labored or painful breathing. (considered "normal" at certain times, e.g. after extreme physical exertion | dyspnea |
| abnormally deep breathing | hyperpnea |
| abnormally rapid, deep, and prolonged breathing caused by CNS disorders, drugs that increase sensitivity of respiratory center, or acute anxiety | hyperventiliation |
| hyperventilation produces respiratory ________ due to reduction in CO2 | alkalosis |
| air hunger, marked increase in depth and rate | kussmaul's respirations |
| inability to breathe except when trunk is in an upright position | orthopnea |
| breathing pattern in which a lung (or a portion of a lung)deflates during inspiration (acts opposite to normal) | paradoxical respirations |
| rate, depth, or tidal volume changes markedly from one interval to the next; pattern of change is periodically reproduced | periodic breathing |
| skin appears blue because of an excesive accomulation of unoxgenated hemoglobin in the blood | cyanosis |
| harsh, high-pitched sound associated with airway obstruction near larynx | stridor |
| normal reflex to remove foreign material from the lungs; normally absent in newborns | cough |
| if the BP cuff is too narrow, what is the result | abnormally high reading |
| if the BP cuff is too wide, what is the result? | abnormally low reading |
| excess hair | hirsutism |
| loss or thinning of hair | alopecia |
| what is the normal angle of a nail bed? | less than or equal to 160 degrees |
| what is clubbing? | nailbed angle is greater than or equal to 180 |
| what causes clubbing? | prolonged decreased oxygenation |
| drooping of upper eyelid | ptosis |
| assesses bone conduction vibrating tuning fork placed in middle of forehead. normal: hear sound equally in ears | Weber test |
| compares bone conduction w/ air conduction; vibrating tuning fork placed on mastoid process; when client no longer hears sounds, positioned in front of ear canal; normal: should still be able to hear sound. air conduction>bone conduction by 2:1 ratio | Rinne test |
| vibration produced when client articulates "99" | tactile fremitus |
| assesses degree and symmetry of diaphragm movement | diaphragmatic |
| soft and low-pitched breezy sounds heard over most of peripheral lung fields; inspiration greater than or equal to expiration | vesicular lung sounds |
| medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration = expiration | brochovesicular |
| loud, course, blowing sound heard over the trachea; inspiration less than equal to expiration | bronchial |
| crackling or gurgling sounds commonly heard on inspiration | crackles (rales) |
| _______ crackles clear with coughing | atelectatic |
| musical sounds or vibrations commonly heard on expiration | sonorous wheeze (rhonchi) |
| squeaky sounds heard during inspiration and expiration associated with narrowed airways | sibilant wheeze |
| grating sounds or vibration heard during inspiration and expiration | pleural friction rub |
| say "99" and and hear more clearly than normal; loud transmission of voice sounds caused by consolidation of lung | bronchophony |
| say "E" and hear "A" due to distortion caused by consolidation of lung | Egophony |
| Hear whispered sounds clearly due to dense consolidation of lung | whispered pectoriloquy |
| manubrial sternal junction at second rib | angle of louis |
| right and left second intercostal spaces alongside sternum | aortic and pulmonic areas |
| third intercostal space just left of sternum | Erb's point |
| Fourth or Fifth intercostal space at lower left of sternal border | tricuspid area |
| fifth intercostal space at left midclavicular line (apex of heart) | mitral area |
| closure of tricuspid and mitral valves; dull quality and low pitch; onset of ventricular systole; louder at apex | S1 |
| closure of aortic and pulmonic valves; snapping quality; onset of diastole; loudest at base | S2 |
| abnormal sounds caused by turbulence within a heart valve | murmurs |
| turbulence within a blood vessel is called what? | a bruit |
| difference between apical and radial rate | pulse deficit |
| which pulse passes medially across the wrist? | radial |
| which pulse passes laterally accross the wrist? | ulnar |
| where is the middle ear located? | temporal bone |
| connects middle ear to the throat and assists in equalizing pressure in middle ear? | Eustachian tube |
| diagnostics with auditory. Quantitative. Degree of loss | Audiogram |
| diagnostics with auditory. Qualitative. Type of loss. | Tuning Fork |
| disorder in auditory canal. causes: infection, inflammation, foriegn body, trama | conductive loss |
| hearing loss due to disorder of the organ of Corti or the auditory nerve. causes: congenital, infection, trama | perspective (sensorineural loss) |
| Name the steps to irrigating an ear | tilt head toward side of infected ear; gently direct stream of fluid against sides of canal; after procedure, instruct patient to lie on affected side to facilitate drainage; contraindicated if there is evidence of swelling or tenderness |
| Name the steps for ear drop instillation | position the affected ear upmost; pull outer ear upward and backward for adults; place drops so they run down the wall of ear canal; have pt lie on unaffected ear to encourage absorption |
| inflammation of mastoid | mastoiditis |
| dilation of the membrane of the labyrinth | Meniere's Disease |
| infection of the middle ear from pathogenic organisms | acute otitis media |
| fibrous outer coat of eye (white) | sclera |
| dome-like structure that forms most of the anterior portion of the eye. main refracting surface of the eye. | cornea |
| lies behind pupil and iris | lens |
| colored portion of the eye; controls amount of light entering eye | iris |
| innermost lining of the eye | retina |
| what is the normal range for specific gravity of urine? | 1.010-1.030 |
| ______ is medium, thud-like or muffled, medium-pitched sounds of short to moderate duration heard over dense fluid-filled tissue such as the liver, spleen, pleural effusion, and diaphragm | dullness |
| ____ is loud, musical or drum-like, high-pitched sound of moderate or long duration heard with enclosed air-filled structures such as the intestines | tympany |
| ______ is very loud, booming, low-pitched sound of long duration heard in conditions of over-inflated air-filled tissue such as occurs in pulmonary emphysema | hyperresonance |
| ______ is very soft, flat, high-pitched sound of short duration heard over very dense tissue such as bone, muscle | flatness |
| pallor (loss of color) is seen with what 3 main things? | 1) arterial insufficiency 2) decreased blood supply 3) anemia |
| cyanosis (blue coloring) is seen with what type of problems? | cardiopulmonary |
| Jaundice is associated with what? | hepatic dysfunction |
| erythema (skin redness and warmth) is seen with what 3 things? | 1)inflammation 2) allergic reactions 3) trauma |
| pale or cyanotic nails are seen with _______ or __________. | hypoxia/ anemia |
| yellow discoloration of nails may be seen with ________ or _________ | fungal infections or psoriasis |
| clubbing of the nails may be the result of _____________ | hypoxia |
| rough, flaky skin may result from: | hypothyroidism |
| excessive moisture may occur with _________ or _________ | fever/hyperthyroidism |
| decreased mobility of the skin is seen with __________ | edema |
| decreased turgor is seen in _________ | dehydration |
| cool skin may be a result of _____ ______ | arterial disease |
| cold skin may accompany __________ or _________ | shock/hypotension |
| a pictoral display of a person's family relationships and medical history. Allows user to visualize hereditary patterns and spychological factors that punctuate relationships | genogram |
| push fluid-filled tissue toward palpating hand so object floats against fingertips | ballottement |
| the diaphram of the stethoscope is used to listen to _____-pitched sounds such as _____, _______ and _______ | high; lung, bowel, heart |
| the bell of the stethoscope is used to listen to ______-pitched sounds such as _____ ______ | low; heart murmurs |
| what is the normal respiration rate for a newborn? | 30-60 per minute |
| what is the normal pulse rate of a newborn? | 120-160 bpm (180 when crying) |
| what is the normal BP of a newborn? | 65/41 mmHg |
| what is the normal respiratory rate of a 1-4 year old? | 20-40 per minute |
| what is the normal pulse rate of a 1-4 year old? | 80-140 bpm |
| what is the normal BP of a 1-4 year old? | 90-99/60-65 mmHg |
| what is the normal respiratory rate of a 5-12 year old? | 15-25 per minute |
| what is the normal pulse rate of a 5-12 year old? | 70-115 bpm |
Created by:
nickijohnson07
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