Health Assessment and Physical Examination - Potter/Perry Chip 16 (9th Edition) THE LATEST UPDATE

Health Assessment and Physical Examination - Potter/Perry Chip 16 (9th Edition) THE LATEST UPDATE QUESTIONS WITH 100% VERIFIED ANSWERS What do you use physical examination to do? - ANSWER-1. gather baseline data about the patient's health status. 2. supplement, confirm, or refute subjective data obtained in the nursing history. 3. identify and confirm nursing diagnosis 4. make clinical decisions about a patient's changing health status and management. 5. evaluate the outcomes of care. What is physiological outcome? - ANSWER-How does the body respond What is cultural sensitivity? - ANSWER-understanding and respecting the values and beliefs that shape those norms and practices when dealing with cultural sensitivity, what do you consider about the patient's health beliefs? - ANSWER-- use of alternative therapies - nutrition habits - relationships with family - comfort and physical closeness during the exam and history What are 4 skills of the physical assessment? - ANSWER-1) inspection 2) palpation 3) auscultation =stethoscope 4) olfaction = smells during the examination what do you observe for in the patient's emotional responses? - ANSWER-his or her facial expressions show fear or concern or if body movements indicate anxiety What should you do during inspection (5) of a patient? - ANSWER-1) adequate lighting 2) position so you can view all surfaces 3) inspect each area for size, shape, color, symmetry, position, abnormalities 4) compare with same are on opposite side 5) do not hurry what are some tips for keeping an examination well organized? - ANSWER-1. compare both sides of the body for symmetry 2. if the patient is seriously ill, first assess the systems of the body most at risk for being abnormal. 3. if the patient becomes fatigued, offer rest periods between assessments. 4. perform painful procedures near the end of an examination. 5. record assessments in specific terms in the electronic or paper record. 6. use common and accepted medical terms and abbreviations to keep notes accurate, brief, and concise. 7. record quick notes during the examination to avoid delays. complete larger documents at the end of the examination. what is palpation? - ANSWER-an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts what do you palpate the skin for? - ANSWER-temp moisture texture turgor tenderness thickness abdomen for tenderness distention masses. what do you use the palmar surface of your hand for? - ANSWER-used to determine position, texture, size,consistency, masses, fluid, and crepitus what do you use the dorsal surface of your hand for? - ANSWERtemperature Olfaction? - ANSWER-- helps to detect abnormalities that cannot be recognized by any other means - can lead to detection of serious abnormalities Preparation for assessment? - ANSWER-- preparing patient - preparing environment - position patient - equipment organized What to keep in mind during an assessment for older adults? - ANSWER-1) do not assume they are sick or disabled 2) allow extra time; don't rush 3) plan your exam to prevent too much movement 4) provide space What is a general survey? - ANSWER-1) assess appearance and behavior 2) assess vital signs 3) assess height and weight (most important for med order purpose) Assessment of the skin includes? - ANSWER-1) color 2) temp 3) moisture 4) texture 5) turgor 6) vascularity 7) edema 8) lesions What is edema? - ANSWER-swelling What is vascularity? - ANSWER-Degree to which the veins in a body part are visible What is turgor? - ANSWER-Elasticity of the skin Assessment of hair and scalp includes? - ANSWER-1) color 2) distribution 3) quantity 4) thickness 5) texture 6) lubrication 7) clean Assessment of nails condition reflects? - ANSWER-- general health - state of nutrition - occupation - level of self-care - age Assessment of the head and neck uses? - ANSWER-1) inspection 2) palpation 3) auscultation assessment of head and neck? - ANSWER-1) position, size, shape, and contour 2) symmetry 3) size, shape, and contour of the skull 4) neck movement What does PERRLA stand for? - ANSWER-Pupils Equal, Round, Reactive to Light Accommodation Assessment of mouth and pharynx includes? - ANSWER-1) color 2) texture 3) hydration (lips) 4) contour 5) lesions 6) teeth 7) gums 8) tongue Assessment of thorax and lungs includes? - ANSWER-Visualize the lobes of the lungs Sounds to label for lung noise? - ANSWER-- adventitious = anything but normal - normal - decreased - absent Assessment of heart includes? - ANSWER-1) find heart and put stethoscope 2) determine the rate 3) is it regular or irregular What is adventitious sounds? - ANSWER-abnormal breath sounds What is arcus senilis? - ANSWER-thin white ring along the margin of the iris What is atrophy? - ANSWER-Inflammation or adhesions What is auscultation? - ANSWER-listening to sounds within the body What is a bruit? - ANSWER-blowing, swooshing sound heard through a stethoscope when an artery is partially occluded What is cerumen? - ANSWER-ear wax What is the costovertebral angle? - ANSWER-formed by the last rib and vertebral column is a landmark used during palpation of the kidney What is crackles (rales)? - ANSWER-fine crackling or bubbling sounds, commonly heard during inspiration when there is fluid in the alveoli What is cyanosis? - ANSWER-bluish discoloration of the skin What is the dorsum? - ANSWER-back of hand What is dyspnea? - ANSWER-difficult or labored breathing (breathlessness) What is dysrhythmia? - ANSWER-failure of the heart to beat at regular successive intervals What is erythema? - ANSWER-redness of the skin What is indurated? - ANSWER-pertaining to an area of hardened tissue What is inspection? - ANSWER-Use of vision to distinguish normal from abnormal findings What is the integument? - ANSWER-Consists of skin, hair, scalp, and nails What is the intercostal spaces? - ANSWER-spaces between the ribs What is jaundice? - ANSWER-yellow-orange discoloration What is olfaction? - ANSWER-smell What is orthopnea? - ANSWER-ability to breathe easily only in an upright position What is pallor? - ANSWER-unusual paleness What is palpation? - ANSWER-Use of hands to touch body parts and make sensitive assessments What is petechiae? - ANSWER-pinpoint-sized, red or purple spots on skin caused by small hemorrhages in the skin layers What is phlebitis? - ANSWER-Inflammation of a vein - occurs commonly after trauma to the vessel wall, infection, immobilization, or prolonged insertion of IV catheters What is a thrill? - ANSWER-Palpable bruit What are the peripheral arteries? - ANSWER-1) radial pulse (thumb side of wrist) 2) ulnar pulse (pinky side of wrist) 3) brachial pulse 4) femoral pulse 5) popliteal pulse 6) dorsalis pedis pulse 7) posterior tibial pulse What is pitting edema? - ANSWER-A depression left in the skin after pressing down What do lymph nodes do? - ANSWER-All blood runs through and is cleaned out Assessment of the abdomen includes? - ANSWER-1) skin 2) umbilicus 3) contour and symmetry 4) enlarges organs or masses 5) movements or pulsations Auscultation of the abdomen includes? - ANSWER-1) divide into 4 sections 2) bowel motility 3) vascular sounds 4) kidney tenderness If there is ever any pain during palpation you should? - ANSWERStop and assess 1) does it hurt more today than yesterday 2) scale of 1-10 What are 2 types of bowel motility and what are they? - ANSWER-1) peristalsis = movement of things through bowel 2) borborygmi = what you can hear with your stethoscope / stomach rumble *Should listen for a full min before stating absent* Palpation of the abdomen - ANSWER-- detects tenderness, distention, or masses - may be light or deep as appropriate What is abdominal distention? - ANSWER-Bloating and swelling in the belly area When conducting an abdominal assessment, the first skill a nurse puts to use is? A) auscultation B) inspection C) palpation D) percussion - ANSWER-B) inspection When do you do a rectum and anus assessment? - ANSWERWhen changing or giving medication What are you checking the skin for during a rectum and anus assessment? - ANSWER-That the skin is not breaking down Assessment of the Musculoskeletal System includes? - ANSWER-- Palpation of joints, bones, and muscles - ROM Why should you do ROM on someone who is unable to move? - ANSWER-To prevent contractures What is contracture? - ANSWER-shortening of a muscle leading to a limited range of motion of joint -due to lack of use, muscles atrophy, common in nursing homes Assessment of the Neurological System - ANSWERThe nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history - ANSWER-Answer: 1. The first part of the general survey is assessment of the appearance and behavior of the patient. As you are initiating the nurse-patient relationship, observe gender and race, age, signs of distress, body type, posture, gait, body movement, hygiene and grooming, dress, affect and mood, speech, and signs of patient abuse. The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps? 1. Percussion 2. Inspection 3. Auscultation 4. Palpation - ANSWER-Answer: 2, 3, 4, 1. The order of an abdominal examination differs slightly from previous assessments. Begin with inspection and follow with auscultation. By using auscultation before palpation there is less chance of altering the frequency and character of bowel sounds. The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2 - ANSWER-Answer: 3. In healthy adults the normal respiratory rates vary from 12 to 20 respirations per minute. A rate of 8 breaths/min is too low and could be caused by anesthesia or opioid sedation effects. The nurse is conducting a skin assessment on a newly admitted patient. Which finding is consistent with the presence of edema? 1. Bluish color around lips and nail beds 2. Dandruff present when the skin is rubbed gently 3. Hypopigmentation on the palms of bilateral hands 4. Swollen bilateral lower extremities - ANSWER-Answer: 4. Edema is when an area becomes larger, swollen, or fluid filled; therefore swollen bilateral lower extremities would be consistent with edema. When completing an abdominal assessment, which action should the nurse perform first? 1. Palpate the large and small intestines. 2. Assess for bowel sounds. 3. Percuss gas within the four quadrants of the abdominal cavity. 4. Focus on areas of pain. - ANSWER-Answer: 2. Inspect and auscultate first, then palpate and percuss. Save the patient's painful area for last Which statements describe accurate completion of a vascular assessment? (Select all that apply.) 1. Simultaneously palpate the carotid arteries. 2. Measure blood pressure. 3. Ask about any pain, cramping, or discomfort in the legs. 4. Count an irregular pulse for 30 seconds and multiply by 2. 5. Rate the strength of a pulse of a scale of 0 to 4. - ANSWERAnswer: 2, 3, 5. A blood pressure measurement is part of the vascular assessment. Asking about pain, cramping, and discomfort in the legs can give insight regarding blood flow to lower extremities and is part of the vascular assessment. During a vascular assessment the rate and strength of a pulse are evaluated on a scale of 0 to 4. Never simultaneously palpate the carotid arteries; they are palpated one at a time. Counting an irregular pulse is part of the vital sign assessment. The nurse would encourage which female patient to have a mammogram? 1. 53year old who had a mammogram completed 6 months ago 2. 20year old with a positive family history of breast disease 3. 41year old at an annual visit who has no complaints 4. 32year old with no family history of breast cancer - ANSWERAnswer: 3. The American Cancer Society guidelines recommend that after 40 years of age, women may begin screening mammograms A patient who has heart failure is complaining of shortness of breath. Which assessment finding is the nurse most concerned about? 1. Moist crackles in the base of bilateral lungs 2. Respiratory rate of 20 3. 1+ edema in lower extremities 4. Bronchovesicular sounds over posterior thorax - ANSWERAnswer: 1. Moist crackles are lower, moist sounds heard during middle of inspiration and are not cleared with coughing. This finding could mean fluid buildup. The nurse provides teaching and answers the patient's questions related to skin care at home. Which statements made by the patient indicate the teaching has been effective? (Select all that apply.) 1. "I will perform the examination in a well lit room and use a mirror." 2. "It is okay if I have drainage from a mole as long as it is not bloody." 3. "The best time for me to avoid the sun is from 10 a.m. to 4 p.m." 4. "Indoor tanning beds are okay to use as long as the use is not excessive." 5. "Some medications can make me more sensitive to the sun." - ANSWER-Answer: 1, 3, 5. A skin examination should be performed in a well-lit room and a mirror should be used to assist the patient to observe areas he or she has difficulty seeing. From 10 a.m. to 4 p.m. is when the sun is most dangerous and should be avoided. Different medications can make patients more sensitive to the sun. Which assessment finding by the nurse correctly describes a vesicle? 1. Irregularly shaped, 2cm raised nevi 2. 0.5cm elevation of the skin filled with serous fluid 3. Thinning of skin that is shiny and transparent 4. Small, flat, nonpalpable change in skin color - ANSWERAnswer: 2. A vesicle is a circumscribed elevation of the skin filled with serous fluid and smaller than 1cm, such as herpes or chickenpox. In which situation would a nurse be using the skill of auscultation? (Select all that apply.) 1. Assessing bowel sounds 2. Assessing oxygen saturation 3. Assessing the size of the liver 4. Assessing for a carotid bruit 5. Assessing orientation - ANSWER-Answer: 1, 4. The skill of auscultation uses a stethoscope and listening. Assessing bowel sounds and assessing for a carotid bruit both require the use of a stethoscope and auscultation How would a nurse complete passive ROM assessment on a patient? (Select all that apply.) 1. Have the patient relax and the nurse moves the joint for the patient. 2. The nurse moves the joint in the appropriate directions. 3. The patient uses muscles and presses back against the nurse's hand. 4. Have the patient ambulate down the hallway and the nurse observes gait. - ANSWER-Answer: 1, 2. Passive ROM involves having the patient relax. The nurse conducting the assessment moves the joint through ROM. The nurse recognizes which assessment findings are considered abnormal? (Select all that apply.) 1. Bowel sounds occurring 60 times per minute 2. Lymph nodes not visible in the neck area 3. Dyspnea present 4. S1 and S2 present 5. Slow reaction time in an 89 year old patient - ANSWERAnswer: 1, 3. Bowel sounds should occur 5 to 35 times per minute; therefore 60 would be too many and abnormal. Dyspnea is an abnormal finding in which a patient experiences breathlessness. Lymph nodes not visible in the neck area, the presence of S1 and S2, and slow reaction time in an elderly patient all are expected and normal findings. A comprehensive physical assessment involves the use of which of the following skills? A. Inspection B. Palpation C. Environment D. Auscultation E. Equipment - ANSWER-ANS: A, B and D Rationale: A comprehensive physical assessment involves the use of five skills: inspection, palpation, percussion, auscultation, and olfaction. A physical examination requires privacy and a comfortable environment for the patient. The person performing the assessment should assemble the necessary equipment prior to beginning. Abnormal breath sounds are also known as _____________. - ANSWER-ANS: Adventitious Rationale: Abnormal sounds result from air passing through moisture, mucus, or narrowed airways. They also result from alveoli suddenly reinflating or from an inflammation between the pleural linings of the lung. Adventitious sounds often occur superimposed over normal sounds. The four types of adventitious sounds are crackles, rhonchi, wheezes, and pleural friction rub. Nursing students may obtain jugular venous pressure measurements with the patient sitting at a 45-degree angle. A. True B. False - ANSWER-ANS: B Rationale: An advanced practice nurse completes the specific measurement of jugular venous pressure. To measure venous pressure, inspect the jugular veins with the patient in the supine position (normally veins protrude), when standing (normally veins are flat), and when sitting at a 45-degree angle (jugular veins are distended only if patient has right-sided heart failure). Which of the following clinical findings indicates central cyanosis? A. Pain in the legs B. Oxygen saturation of 98% C. Bluish discoloration of the lips and mouth D. Bounding femoral artery pulses - ANSWER-ANS: C Rationale: The presence of cyanosis requires special attention. Heart disease sometimes causes central cyanosis (bluish discoloration of the lips, mouth, and conjunctivae), indicating poor arterial oxygenation. Blue lips, earlobes, and nail beds are signs of peripheral cyanosis, which indicates peripheral vasoconstriction. When cyanosis is present, consult with a health care provider to have laboratory testing of oxygen saturation, to determine severity of the problem. Examination of the nails involves inspection for clubbing (a bulging of the tissues at the nail base), resulting from insufficient oxygenation at the periphery. Pain in the legs and bounding femoral pulses are not indicative of central cyanosis. Jane is preparing to perform a physical assessment on Mr. Neal. Which of the following interventions will be helpful in the physical preparation of the patient? (Select all that apply.) A. Ask Mr. Neal if he is anxious or stressed. B. Obtain an interpreter. C. Offer to assist Mr. Neal to the restroom. D. Provide privacy and warm blankets if needed. E. Assist Mr. Neal to a position of comfort. - ANSWER-ANS: C, D and E Rationale: The patient's physical comfort is vital for a successful examination. Before starting, ask if the patient needs to use the restroom. Physical preparation involves being sure the patient is dressed or covered properly, providing warm blankets if needed, and assisting the patient to assume a position of comfort. Psychological preparation of the patient involves assessing for stress or anxiety and providing an interpreter if needed.