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Exam (elaborations)

NUR 500 HEALTH ASSESSMENT QUESTIONS WITH COMPLETE SOLUTIONS

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NUR 500 HEALTH ASSESSMENT QUESTIONS WITH COMPLETE SOLUTIONS

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NUR 500 HEALTH ASSESSMENT QUESTIONS WITH
COMPLETE SOLUTIONS

- evaluated intensity of spoken voice
~have client say "e-e-e" each time stethoscope placed on skin
~normal you should hear "eeeee" Correct Answer Echophony

90 degrees or less meet at ziphoid process Correct Answer
costal angle

anterior thoracic landmarks Correct Answer suprasternal
notch
sternum
sternal angle

at the base of the neck 2 bumps at c7 and lower is t1 Correct
Answer landmark cervical prominence (bony spur)

exaggerated bronchophony
have client whisper "1-2-3" each time stethoscope placed on
skin: normal is a faint, muffled, and almost inaudible sound
Correct Answer Whispered pectoriloquy

Examination of external chest 4 steps Correct Answer palpate
trachea for position
palpate anterior and posterior chest wall
palpate for thoracic expansion
palpate for vocal fremitus

hands on posterolateral chest wall thumbs at T9 OR T10 slide
hands medially to pinch up small fold of skin ask patient to take

, deep breath- no lag should be found once thumbs seperate
symmetrically Correct Answer thoracic expansion

inspiration < expiration
harsh hollow tubular
can hear in anterior only Correct Answer Bronchial sounds

inspiration = expiration
mixed sounds
can hear in both anterior and posterior Correct Answer
Bronchialvescicular sounds

inspiration > expiration
rustling, like a sound of wind in the trees
can hear in anterior, posterior and lateral sides Correct Answer
vescicular sounds

Intermittent cough problems Correct Answer am or eve -
exposure to irritants
night - postnasal drip
early am - chronic bronchial inflammation of smokers

Leave stethoscope in one place long enough to hear at least one
complete inspiratory & expiratory cycle
Side-to-side comparison most important Correct Answer
auscultation of lungs

located symmetrically in each hemithorax, lower tip is at 7/8th
rib Correct Answer landmark of scapula

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