NUR 104 Exam 1 with answers

NUR 104 Exam 1 with answers
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Identify the purposes of the physical health examination. -
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CORRECT ANSWERS ✔✔to obtain baseline data
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to identify nursing diagnosis, collaborative problems, and
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wellness diagnosis |\




to monitor the status of a previously identified problem
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to screen for health problems
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Describe appropriate physical assessment techniques. - CORRECT
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ANSWERS ✔✔In order:
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inspection- use of sight to gather data (example, observing the
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patient's gait, personal hygiene, affect, and behavior)
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palpation- use of touch to gather data (example, observing
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temperature; skin texture; moisture; anatomical landmarks; and |\ |\ |\ |\ |\ |\ |\


abnormalities such as edema, masses, or areas of tenderness) |\ |\ |\ |\ |\ |\ |\ |\




percussion- tapping your fingers on the skin using short strokes
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(example, when assessing abdomen and lungs, tapping produces
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vibrations and allows you to determine location, size, and density
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of underlying structures)
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auscultation- use of hearing to gather data (example, hearing |\ |\ |\ |\ |\ |\ |\ |\ |\


wheezing or chest congestion or using stethoscope)
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sometimes, olfaction- use of the sense of smell to gather data
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(example, if a client is slurring his words he might smell of
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alcohol
exception: when performing an abdominal assessment, perform
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auscultation before percussion and palpation to avoid disturbing
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the abdominal sounds.
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, Explain the significance of selected physical assessment findings.
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- CORRECT ANSWERS ✔✔
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Describe suggested sequencing to conduct a physical health
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examination in an orderly fashion. - CORRECT ANSWERS |\ |\ |\ |\ |\ |\ |\ |\


✔✔General survey • Vital signs • Head • Hair, scalp, face • Eyes
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and vision • Ears and hearing • Nose • Mouth and oropharynx •
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Neck • Muscles • Lymph nodes • Trachea • Thyroid gland •
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Carotid arteries • Neck veins • Upper extremities • Skin and nails
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• Muscle strength and tone • Joint range of motion • Brachial
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and radial pulses • Sensation • Chest and back • Skin • Thorax
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shape and size • Lungs • Heart • Spinal column • Breasts and
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axillae • Abdomen • Skin • Abdominal sounds • Femoral pulses •
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External genitals • Anus • Lower extremities • Skin and toenails
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• Gait and balance • Joint range of motion • Popliteal, posterior
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tibial, and dorsalis pedis pulses
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Predict the variations in health assessment findings of clients
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across the life span. - CORRECT ANSWERS ✔✔
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Demonstrate appropriate documentation and reporting of health |\ |\ |\ |\ |\ |\ |\


assessment findings. - CORRECT ANSWERS ✔✔ |\ |\ |\ |\ |\




Describe variations in the depth and breadth of performing a
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health assessment according to the client circumstances. -
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CORRECT ANSWERS ✔✔ |\ |\




SPICES - CORRECT ANSWERS ✔✔Sleep disorders
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