NUR 122: Exam 1 UPDATED ACTUAL Questions and CORRECT
Answers
4 techniques of physical assessment 1. inspection: visualizing
2. palpation: feeling
3. percussion: tapping to hear sounds
4. auscultation: listening
Purpose of physical assessment To establish the patient's current condition, a baseline against which future
changes may be measured
To identify problems the patient may have or have the potential to develop
To evaluate the effectiveness of nursing interventions
To monitor for changes in body function
To detect specific body systems that need further assessment or testing
Priority Physical Assessments ---Life threatening---
-severe bleeding
-ABCs
-something lodged in someones throat
Secondary Physical Assessments ---requires prompt attention to prevent further progression---
-chest pain
-lab values: potassium, mag, troponin, WBC
Tertiary Physical Assessments ---important, not immediate---
-dressing change
-temp
-BP
-pain (WILDA)
Short-term memory assessment -name 3 objects & having them repeat it back
Long-term memory assessment name 3 presidents from the last 100 years
Abdomen assessment -inspection: visualization
-auscultation: listen
-percussion: tympany sounds
-palpation: feel
How long to wait when listening if no bowel sounds 3-5 minutes
present?
How often do you hear bowel sounds in a hyperactive constant gurgling more than every 5-15 seconds
bowel?
How often do you hear bowel sounds in a hypoactive 1 sound every 15 seconds or more
bowel?
Answers
4 techniques of physical assessment 1. inspection: visualizing
2. palpation: feeling
3. percussion: tapping to hear sounds
4. auscultation: listening
Purpose of physical assessment To establish the patient's current condition, a baseline against which future
changes may be measured
To identify problems the patient may have or have the potential to develop
To evaluate the effectiveness of nursing interventions
To monitor for changes in body function
To detect specific body systems that need further assessment or testing
Priority Physical Assessments ---Life threatening---
-severe bleeding
-ABCs
-something lodged in someones throat
Secondary Physical Assessments ---requires prompt attention to prevent further progression---
-chest pain
-lab values: potassium, mag, troponin, WBC
Tertiary Physical Assessments ---important, not immediate---
-dressing change
-temp
-BP
-pain (WILDA)
Short-term memory assessment -name 3 objects & having them repeat it back
Long-term memory assessment name 3 presidents from the last 100 years
Abdomen assessment -inspection: visualization
-auscultation: listen
-percussion: tympany sounds
-palpation: feel
How long to wait when listening if no bowel sounds 3-5 minutes
present?
How often do you hear bowel sounds in a hyperactive constant gurgling more than every 5-15 seconds
bowel?
How often do you hear bowel sounds in a hypoactive 1 sound every 15 seconds or more
bowel?
