NUR 151 Exam 2 questions with |\ |\ |\ |\ |\ |\
answers
Define Inspection |\
-Process of performing deliberate, purposeful
|\ |\ |\ |\ |\
observations in a systematic manner. |\ |\ |\ |\
-begins with the initial patient contact and continues
|\ |\ |\ |\ |\ |\ |\ |\
through the entire assessment. |\ |\ |\
-usually followed by palpation during the assessment of
|\ |\ |\ |\ |\ |\ |\ |\
each body part. |\ |\
How do you preform an inspection?
|\ |\ |\ |\ |\
Observe visually, hearing, and smell to gather data
|\ |\ |\ |\ |\ |\ |\
Assess appearance, behavior, and movement
|\ |\ |\ |\
lighting is essential for distinguishing the color, texture,
|\ |\ |\ |\ |\ |\ |\ |\
and moisture of body surfaces.
|\ |\ |\ |\
Inspect each area of the body for size, color, shape,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
position, movement, and symmetry |\ |\ |\
Define Palpation |\
-uses the sense of touch
|\ |\ |\ |\
-hands and fingers are sensitive tools that can assess skin
|\ |\ |\ |\ |\ |\ |\ |\ |\
temperature, turgor, texture, and moisture, as well as
|\ |\ |\ |\ |\ |\ |\ |\ |\
vibrations within the body (such as the heart) and shape
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
or structures within the body (e.g., the bones).
|\ |\ |\ |\ |\ |\ |\
What is percussion? |\ |\
-the act of striking one object against another to produce
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
sound
-The fingertips are used to tap the body over body tissues
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
to produce vibrations and sound waves.
|\ |\ |\ |\ |\ |\
,-The characteristics of the sounds produced are used to
|\ |\ |\ |\ |\ |\ |\ |\ |\
assess the location, shape, size, and density of tissues
|\ |\ |\ |\ |\ |\ |\ |\
-Abnormal sounds suggest alteration of tissues or the
|\ |\ |\ |\ |\ |\ |\ |\
presence of a mass |\ |\ |\
-usually performed by advanced practice professionals
|\ |\ |\ |\ |\
Auscultation
-the act of listening with a stethoscope to sounds
|\ |\ |\ |\ |\ |\ |\ |\ |\
produced within the body. -performed by placing the
|\ |\ |\ |\ |\ |\ |\ |\
stethoscope diaphragm or bell against the body part |\ |\ |\ |\ |\ |\ |\ |\
being assessed
|\
-expose the part listened to, use the proper part of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
stethoscope for specific sounds, and listen in a quiet |\ |\ |\ |\ |\ |\ |\ |\ |\
environment
What can the nurse do to prepare the patient for the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment? What/how could the nurse help the patients |\ |\ |\ |\ |\ |\ |\ |\
during this process?
|\ |\
remain sensitive to the patient's physiologic needs (e.g.,
|\ |\ |\ |\ |\ |\ |\ |\
pain or decreased stamina because of age or illness) and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
psychological needs (e.g., anxiety about having the |\ |\ |\ |\ |\ |\ |\
examination).
Explain that the first part of the assessment will involve
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
questions about the patient's health concerns, health
|\ |\ |\ |\ |\ |\ |\
habits, and lifestyle and that the information will only be
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
shared with the patient's other health care providers.
|\ |\ |\ |\ |\ |\ |\
Inform the patient that after the health history is
|\ |\ |\ |\ |\ |\ |\ |\ |\
completed, body structures will be examined. |\ |\ |\ |\ |\
Reassure the patient by explaining that the assessments
|\ |\ |\ |\ |\ |\ |\ |\
should not be painful. Explaining the assessment in
|\ |\ |\ |\ |\ |\ |\ |\
general terms can help decrease the patient's
|\ |\ |\ |\ |\ |\ |\
embarrassment, fear of possible abnormal physical |\ |\ |\ |\ |\ |\
findings, or fear of "failing" a test. Be sure to then explain
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
each assessment in greater detail as it is performed.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Explain that drapes will be used during the examination,
|\ |\ |\ |\ |\ |\ |\ |\ |\
, and only the area being assessed will be exposed. Answer
|\ |\ |\ |\ |\ |\ |\ |\ |\
the patient's questions directly and honestly.
|\ |\ |\ |\ |\ |\
subjective data |\
things a person tells you about that you cannot observe
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
through your senses; symptoms |\ |\ |\
should try to validate |\ |\ |\
objective data |\
information that is seen, heard, felt, or smelled |\ |\ |\ |\ |\ |\ |\
signs
vitals
lab work
|\
imaging
validate
How do you validate data?
|\ |\ |\ |\
Distinguish normal from abnormal |\ |\ |\
Identify gaps or inconsistencies |\ |\ |\
Repeat and reassess |\ |\
Look for etiology, influence
|\ |\ |\
Look for clusters of data, patterns
|\ |\ |\ |\ |\
Throw out irrelevant data |\ |\ |\
Consensus
Don't make assumptions |\ |\
recheck data/information |\
look for factors (has this happened before physiological,
|\ |\ |\ |\ |\ |\ |\ |\
emotional etc.) that may be present |\ |\ |\ |\ |\
ask someone else if they see or hear what we are seeing
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
comprehensive health assessment |\ |\
answers
Define Inspection |\
-Process of performing deliberate, purposeful
|\ |\ |\ |\ |\
observations in a systematic manner. |\ |\ |\ |\
-begins with the initial patient contact and continues
|\ |\ |\ |\ |\ |\ |\ |\
through the entire assessment. |\ |\ |\
-usually followed by palpation during the assessment of
|\ |\ |\ |\ |\ |\ |\ |\
each body part. |\ |\
How do you preform an inspection?
|\ |\ |\ |\ |\
Observe visually, hearing, and smell to gather data
|\ |\ |\ |\ |\ |\ |\
Assess appearance, behavior, and movement
|\ |\ |\ |\
lighting is essential for distinguishing the color, texture,
|\ |\ |\ |\ |\ |\ |\ |\
and moisture of body surfaces.
|\ |\ |\ |\
Inspect each area of the body for size, color, shape,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
position, movement, and symmetry |\ |\ |\
Define Palpation |\
-uses the sense of touch
|\ |\ |\ |\
-hands and fingers are sensitive tools that can assess skin
|\ |\ |\ |\ |\ |\ |\ |\ |\
temperature, turgor, texture, and moisture, as well as
|\ |\ |\ |\ |\ |\ |\ |\ |\
vibrations within the body (such as the heart) and shape
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
or structures within the body (e.g., the bones).
|\ |\ |\ |\ |\ |\ |\
What is percussion? |\ |\
-the act of striking one object against another to produce
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
sound
-The fingertips are used to tap the body over body tissues
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
to produce vibrations and sound waves.
|\ |\ |\ |\ |\ |\
,-The characteristics of the sounds produced are used to
|\ |\ |\ |\ |\ |\ |\ |\ |\
assess the location, shape, size, and density of tissues
|\ |\ |\ |\ |\ |\ |\ |\
-Abnormal sounds suggest alteration of tissues or the
|\ |\ |\ |\ |\ |\ |\ |\
presence of a mass |\ |\ |\
-usually performed by advanced practice professionals
|\ |\ |\ |\ |\
Auscultation
-the act of listening with a stethoscope to sounds
|\ |\ |\ |\ |\ |\ |\ |\ |\
produced within the body. -performed by placing the
|\ |\ |\ |\ |\ |\ |\ |\
stethoscope diaphragm or bell against the body part |\ |\ |\ |\ |\ |\ |\ |\
being assessed
|\
-expose the part listened to, use the proper part of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
stethoscope for specific sounds, and listen in a quiet |\ |\ |\ |\ |\ |\ |\ |\ |\
environment
What can the nurse do to prepare the patient for the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment? What/how could the nurse help the patients |\ |\ |\ |\ |\ |\ |\ |\
during this process?
|\ |\
remain sensitive to the patient's physiologic needs (e.g.,
|\ |\ |\ |\ |\ |\ |\ |\
pain or decreased stamina because of age or illness) and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
psychological needs (e.g., anxiety about having the |\ |\ |\ |\ |\ |\ |\
examination).
Explain that the first part of the assessment will involve
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
questions about the patient's health concerns, health
|\ |\ |\ |\ |\ |\ |\
habits, and lifestyle and that the information will only be
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
shared with the patient's other health care providers.
|\ |\ |\ |\ |\ |\ |\
Inform the patient that after the health history is
|\ |\ |\ |\ |\ |\ |\ |\ |\
completed, body structures will be examined. |\ |\ |\ |\ |\
Reassure the patient by explaining that the assessments
|\ |\ |\ |\ |\ |\ |\ |\
should not be painful. Explaining the assessment in
|\ |\ |\ |\ |\ |\ |\ |\
general terms can help decrease the patient's
|\ |\ |\ |\ |\ |\ |\
embarrassment, fear of possible abnormal physical |\ |\ |\ |\ |\ |\
findings, or fear of "failing" a test. Be sure to then explain
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
each assessment in greater detail as it is performed.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Explain that drapes will be used during the examination,
|\ |\ |\ |\ |\ |\ |\ |\ |\
, and only the area being assessed will be exposed. Answer
|\ |\ |\ |\ |\ |\ |\ |\ |\
the patient's questions directly and honestly.
|\ |\ |\ |\ |\ |\
subjective data |\
things a person tells you about that you cannot observe
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
through your senses; symptoms |\ |\ |\
should try to validate |\ |\ |\
objective data |\
information that is seen, heard, felt, or smelled |\ |\ |\ |\ |\ |\ |\
signs
vitals
lab work
|\
imaging
validate
How do you validate data?
|\ |\ |\ |\
Distinguish normal from abnormal |\ |\ |\
Identify gaps or inconsistencies |\ |\ |\
Repeat and reassess |\ |\
Look for etiology, influence
|\ |\ |\
Look for clusters of data, patterns
|\ |\ |\ |\ |\
Throw out irrelevant data |\ |\ |\
Consensus
Don't make assumptions |\ |\
recheck data/information |\
look for factors (has this happened before physiological,
|\ |\ |\ |\ |\ |\ |\ |\
emotional etc.) that may be present |\ |\ |\ |\ |\
ask someone else if they see or hear what we are seeing
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
comprehensive health assessment |\ |\
