Chapter 13 Timby Fundamentals
2024/2025
*Lightly touching or applying pressure* to the body using fingertips, back of hand, or palm of
hand. *Surface of skin and feeling vibration* -- Correct Answer --Palpation
Providing info:
-*Temp*
-*Moisture*
-*Tenderness*
-*Vibrations*
*Striking or tapping the body with fingertips* to produce vibratory sounds -- Correct Answer --
Percussion
-Least used by nurses
Sounds:
-Empty= Resonant
-Thud= Dull
4 basic physical assessment techniques -- Correct Answer ---Inspection
-Percussion
-Palpation
-Auscultation
6 general areas for data collection -- Correct Answer --1. Head and Neck
2. Chest
3. Extremities
,4. Abdomen
5. Genitalia
6. Anus and Rectum
Ability of pupils to *constrict when looking at a near object* and *dilate when looking at an
object in the distance* -- Correct Answer --Accommodation
-Light close to eye: Eye Constrict
-Light further away: Eye Dilates
Ability to see both far and near -- Correct Answer --Visual Acuity
*Always appropriate to ask* if pt wears glasses, contacts, false eye, or consider themselves blind
Abnormal heart sounds -- Correct Answer --S3: *Lub Dub, Dub*-- (Ken-tuck-*Y*)
S4: *Lub, Lub Dub*-- (*T*en-nes-see)
Abnormal sounds that are *grating and leathery sounds* caused by 2 dry pleural surfaces moving
over each other -- Correct Answer --Pleural Friction Rubs
Abnormal sounds that are *whistling or squeaking sounds* caused by air moving through a
narrowed passage -- Correct Answer --Wheezes
-Heard: Anywhere in the chest during *Inspirations and expirations*
*Suddenly stops: Air passage is TOTALLY occluded*
(Can't breathe due to respiratory arrest)
Abnormal sounds that are Intermittent, high-pitched, popping heard primarily during inspiration
-- Correct Answer --Crackles
, *Sound like rice crispy*
-Not cleared with coughing
-Opening of partially collapsed alveoli (terminal air sacs)
-Movement of air over min amount of fluid in the periphery of the lungs during *inspirations*
Abnormal sounds that are low-pitched, continuous, bubbling and heard in larger airways --
Correct Answer --Gurgles (Rhonchi)
-Prominent during *expiration*
-Clear with coughing or suctioning
Appears in the midline with gentle concave and convex curves when viewed from the side --
Correct Answer --Spine
-Shoulder should be *equal height*
Normal: No curve
Assessment of hair -- Correct Answer ---Scalp hair, eyebrow, and eyelashes
-Debris: Blood from head trauma
-Nits: Lice eggs
-Scalp lesions
Assessment of Muscle Strength -- Correct Answer ---Extremity Separately
-Grasp
-Pull and pushes on upper and lower extremities
2024/2025
*Lightly touching or applying pressure* to the body using fingertips, back of hand, or palm of
hand. *Surface of skin and feeling vibration* -- Correct Answer --Palpation
Providing info:
-*Temp*
-*Moisture*
-*Tenderness*
-*Vibrations*
*Striking or tapping the body with fingertips* to produce vibratory sounds -- Correct Answer --
Percussion
-Least used by nurses
Sounds:
-Empty= Resonant
-Thud= Dull
4 basic physical assessment techniques -- Correct Answer ---Inspection
-Percussion
-Palpation
-Auscultation
6 general areas for data collection -- Correct Answer --1. Head and Neck
2. Chest
3. Extremities
,4. Abdomen
5. Genitalia
6. Anus and Rectum
Ability of pupils to *constrict when looking at a near object* and *dilate when looking at an
object in the distance* -- Correct Answer --Accommodation
-Light close to eye: Eye Constrict
-Light further away: Eye Dilates
Ability to see both far and near -- Correct Answer --Visual Acuity
*Always appropriate to ask* if pt wears glasses, contacts, false eye, or consider themselves blind
Abnormal heart sounds -- Correct Answer --S3: *Lub Dub, Dub*-- (Ken-tuck-*Y*)
S4: *Lub, Lub Dub*-- (*T*en-nes-see)
Abnormal sounds that are *grating and leathery sounds* caused by 2 dry pleural surfaces moving
over each other -- Correct Answer --Pleural Friction Rubs
Abnormal sounds that are *whistling or squeaking sounds* caused by air moving through a
narrowed passage -- Correct Answer --Wheezes
-Heard: Anywhere in the chest during *Inspirations and expirations*
*Suddenly stops: Air passage is TOTALLY occluded*
(Can't breathe due to respiratory arrest)
Abnormal sounds that are Intermittent, high-pitched, popping heard primarily during inspiration
-- Correct Answer --Crackles
, *Sound like rice crispy*
-Not cleared with coughing
-Opening of partially collapsed alveoli (terminal air sacs)
-Movement of air over min amount of fluid in the periphery of the lungs during *inspirations*
Abnormal sounds that are low-pitched, continuous, bubbling and heard in larger airways --
Correct Answer --Gurgles (Rhonchi)
-Prominent during *expiration*
-Clear with coughing or suctioning
Appears in the midline with gentle concave and convex curves when viewed from the side --
Correct Answer --Spine
-Shoulder should be *equal height*
Normal: No curve
Assessment of hair -- Correct Answer ---Scalp hair, eyebrow, and eyelashes
-Debris: Blood from head trauma
-Nits: Lice eggs
-Scalp lesions
Assessment of Muscle Strength -- Correct Answer ---Extremity Separately
-Grasp
-Pull and pushes on upper and lower extremities
