Chapter 30 Health Assessment and Physical Examination/ Potter and Perry

Chapter 30 Health Assessment and Physical Examination/ Potter and Perry questions and answers. Five nursing purposes for performing a physical assessment: - correct answers.1) Gather baseline data about the patient's health status. 2) Support and refute subjective data obtained in nursing history. 3) Confirm and identify nurse's diagnoses. 4) Make clinical judgments about patient's changing health status and management. Principles related to the nurse performing daily physical examinations: - correct answers.1) A head-to-toe physical assessment is required daily. 2) Reassessment is performed when the patient's condition changes as it improves or worsens. 3) The environment equipment and the patient are properly prepared. 4) Safety for confused patients should be a priority. Proper examination includes: - correct answers.a) Infection control (wash hands before & after visit, wear gloves) b) A private environment c) Equipment needed should be ready at bedside d) Physical preparation of the patient. e) Psychological preparation of the patient. (Let the patient know what you are going to do) purposes for performing a physical assessment - correct answers. Seven variation in the nurse's individual style that are appropriate when examining children: - correct answers.1) Gather all the parts and histories and children from parents. 2) Perform the examination in a nonthreatening area and provide time for play. 3) Offer support to the parents during the examination and do not pass judgment. 4) Call children by their first names and address their parents as Mr. and Mrs. 5) Use open-end questions to allow parents to share more information. 6) Treat adolescents as adults. 7) Provide confidentiality for adolescents; speak to them alone. Seven variations in the nurse's individual style that are appropriate when examining and older adult. - correct answers.1) Do not stereotype the aging patients' level of cognition. 2) Be sensitive to sensory or physical limitations, (more time). 3) Adequate space is needed. 4) Use patience, allow for pauses, and observe for details. 5) Certain types of information may be stressful to give. 6) Perform examination near bathroom facilities. 7) Be alert for signs of increasing fatigue. Principles to follow to keep an examination well organized: - correct answers.1) Compare both sides for symmetry 2) If the patient is ill, first assess the systems of the body part that is most at risk. 3) Offer rest periods if the patient becomes fatigued. 4) Record assessments in specific terms in the record. 5) Use common and accepted medical terms and abbreviations. 6) Record quick notes during examination to avoid delays. Inspection: - correct answers.Is looking, listening and smelling to distinguish normal form abnormal findings. Guidelines to achieve the best results during inspection: - correct answers.a) Adequate lighting is available. b) Use a direct light source. c) Inspect each area for size, shape, and color. d) Position and expose body parts as needed, maintaining privacy. e) Validate findings with the patient. Palpation: - correct answers.Involves using hands to touch body parts. light palpation - correct ves pressing inward 1 cm (superficial) Deep palpation - correct ves depressing the area 4 cm to assess the condition of organs. Auscultation - correct listening to the internal sounds the body makes. Auscultation described as - correct answers.a) Frequency indicates the number of sound waves cycles generated per second by a vibrating object. b) Amplitude describes the loudness, soft to loud. c) Quality describes sound of similar frequency and loudness. d) Duration describes length of time that sound vibrations last. Observations of the patient's general appearance and behavior that should be viewed - correct answers.a) Gender b) Age c) Signs of distress d) Body type e) Posture f) Gait g) Body Movements h) Hygiene and grooming i) Dress j) Body odor k) Affect and mood l) Speech possible abuse - correct answers.Physical injury or neglect, (evidence of malnutrition or presence of bruising). Also watch for fear of spouse or partner, caregiver, or parent. The following are related to the acronym CAGE - correct answers.C: Have you ever felt the need to cut down on your use? A: Have people annoyed you by criticizing you use? G: Have you ever felt bad or guilty about your use? E: Have you ever used or had a drink first thing in the morning as an "eye opener" to steady you nerves or feel normal? Three actions that should be taken to ensure accurate weight measurement of a hospitalized patient - correct answers.a) Weigh patients at the same time of day. b) Weigh patients at the same scale. c) Weigh patients in the same clothes. Assessment of skin reveals the patient's health status: - correct answers.a) Oxygenation b) Circulation c) Nutrition d) Local tissue damage e) Hydration Risk for skin lesions in hospitalized patients: - correct answers.a) Exposure to pressure during immobilization. b) Various medications c) Neurological impairment d) Chronic illness e) Orthopedic injury f) Diminished mental status g) Poor tissue oxygenation h) Low cardiac output i) Inadequate nutrition Pigmentation - correct skin color. It is usually uniform over the body Physical findings of the skin that is indicative of substance abuse: - correct answers.Physical findings of the skin that is indicative of substance abuse: Indurated - correct hardened Turgor - correct skin elasticity Edema - correct areas of the skin that are swollen or edematous from a buildup of fluid in the tissues. Senile keratosis - correct a thickening of skin. Cherry angiomas - correct ruby-red papules. Three type of lice: - correct answers.a) Pediculus humanus capitis (head lice) b) Pediculus humanus corporis (body lice) c) Pediculus pubis (Crab lice) Clubbing - correct a change in the angle between the nail and nail base, including softening, flattening, and enlargement of fingertips. Beau lines - correct transverse depression in the nails. Koilonychia - correct concave curves. Splinter hemorrhages - correct red or brown linear streaks in nail beds. Paronychia - correct inflammation of the skin at base of nail. Hydrocephalus - correct the buildup of cerebrospinal fluid in the ventricles. Acromegaly - correct a condition that causes enlarged jaws and facial bones in adults. Hyperopia - correct refractive error causing farsightedness Myopia - correct refractive error causing nearsightedness. Presbyopia - correct impaired near vision in middle-age and older adults caused by loss of elasticity of the lens.