Quiz 1: NURS190 / NURS 190 (Latest 2026 / 2027 Update) Physical Assessment | Questions & Answers | Grade A | 100% Correct – WCU

Quiz 1: NURS190 / NURS 190 (Latest 2026 / 2027 Update) Physical Assessment | Questions & Answers | Grade A | 100% Correct – WCU Q: 4 basic physical assessment techniques Answer inspection palpation percussion auscultation Q: How to do a physical assessment on the abdomen? And why? Answer inspection auscultation percussion palpation - so that we DO NOT allow for hyperactive bowel sounds before auscultating Q: What are the sensitive areas of the hand? Answer • The finger pads are used for discrimination of underlying structures and functions such as pulses, superficial lymph nodes, or crepitus. • Vibrations (vibrations) are best perceived by the examiner when using the base of the fingers (metacarpophalangeal joints). • The ulnar surface of the hand, including the finger, is most sensitive to vibrations such as fremitus. • The palmar aspect of the fingers is used to determine position, consistency, texture, size of structures, pain, and tenderness. • The dorsal surface of the fingers is most sensitive to temperature. • The dominant hand is always more sensitive than the non-dominant hand. Q: What is light palpation used for? Answer Light palpation is used with the pads of the fingers to help assess the skin surface, pulses, textures, tenderness (1cm) Q: What is deep palpation? Answer Used to palpate abdomen and internal organs (2-4cm) Q: What is contraindicated for deep palpation? Answer Dissecting aneurysms, peritonitis, ectopic pregnancy Q: What is percussion? Answer tapping the person's skin with short, sharp strokes to assess underlying structures Q: What is direct percussion? Answer Technique of tapping the body with the fingertips of the dominant hand. Q: What is direct percussion used to assess for? Answer Adult sinuses Q: What is blunt percussion? Answer Non dominant hand is flat and dominant hand hits over non dominant with a fist Q: What is blunt percussion used for? Answer Assess for pain and tenderness in gallbladder, liver, and kidneys Q: What is indirect percussion? Answer It's the technique most commonly used (sounds are clearer & more easily interpreted). A hammer or tapping finger is used Q: What is a tympany sound? Answer loud, high pitched Q: Where would you hear a tympanic sound? Answer stomach or intestines Q: What is a resonance sound? Answer loud, low pitched, hollow Q: Where would you hear a resonance sound? Answer lungs Q: What is a hyperresonance sound? Answer loud, low pitched Q: Where would you hear a hyper resonance sound? Answer air is trapped in lungs, common among the elderly Q: What is a dullness sound? Answer soft, high-pitched Q: Where would you hear a dullness sound? Answer solid body organs- liver or stool-filled colon Q: What is a flatness sound? Answer soft, high-pitched Q: Where would you hear a flatness sound? Answer solid tissue- muscle and bone Q: What is a goniometer? Answer measures the degree of joint and flexion and extension Q: What is the skin fold caliper? Answer measure the thickness of subcutaneous tissue What is a transilluminator? Answer detects blood, fluid, or masses in body cavities What are wood lamps? Answer detects fungal infections of the skin What is a monofilament? Answer Assesses neuropathy of diabetic patients What are the parts of the stethoscope? Binaurals (earpieces) felxible tubing end piece (bell and diaphragm) Bell vs. Diaphragm Bell is for low pitch sounds (murmurs) Diaphragm is used for high pitch sounds (heart and lung sounds) Can you hear better with short or long tubing of the stethoscope? short tubing What is a doppler? Uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope Ex) fetal heart sounds and peripheral pulses that cannot be easily palpated What is an opthalmoscope? used to view internal structure of the eye What is an otoscope? inspects the external ear structures What should patients do before an examination? empty their bladder remove clothing, jewelry, hair pieces, enamel What makes up the integumentary system? skin, hair, nails The cutaneous membrane is made up of what? Epidermis and dermis What is the epidermis? and what do they produce? outermost layer of skin About 25% of the cells in the stratum basale are melanocytes, which produce the skin pigment called melanin. What is the dermis? layer of connective tissue that lies just below the epidermis collagen- gives skin toughness elastin- elasticity What is subcutaneous tissue? AKA? Hypodermis store's body's fat cells. used for cushion and insulation What is eccrine? More numerous and more widely distributed. They produce a clear perspiration mostly made up of water and salts, which they release into funnel-shaped pores at the skin surface. What is apocrine? Found primarily in the axillary and anogenital regions. They are dormant until the onset of puberty. Apocrine glands produce a secretion made up of water, salts, fatty acids, and proteins, which is released into hair follicles. When apocrine sweat mixes with bacteria on the skin surface, it assumes a musky odor. Sebaceous glands secrete sebum (oil) into the hair follicles where the hair shafts pass through the dermis arrector pili A muscle that causes the hair to contract and stand upright when a person is under stress or exposed to cold. Nails Thin plates of keratinized epidermal cells that shield the distal ends of the fingers and toe protect the dorsal surface of the last bone of each toe and finger What is trichotillomania? hair pulling/twisiting disorder Some individuals with dark skin have increased pigmentation in the creases of the palms and soles, as well as yellow or brown-tinged sclerae. These are normal findings. Vitiligo It's patchy & depigmented areas over the face, neck, hands feet & body folds Most common among darker skin tones Severe disturbance of body image Pitting edema It's a decrease in skin mobility caused by accumulation of fluid in the intercellular spaces. Skin looks puffy, pitted & tight. It's most noticeable in the hands, feet, ankles & sacral area. Pitting edema scale ABCDEs of melanoma asymmetry border irregularity color diameter greater than 6mm evolution Schamroth technique - used to check for clubbing - hold thumb together, normal should form a triangle - abnormal, broken triangle Macula/Patch Flat, non-palpable changes in the skin Macula- petechiae Patch- port wine stain Papule/Plaque Elevated, solid palpable masses with borders Papule- elevated moles, warts Plaques- psoriasis Erosion/fissure Wearing away of the superficial epidermis causing a moist shallow depression crack erosion- scratch marks fissure- corner of mouth/athlete's foot keloid/ lichenification An elevated, irregular, darkened area of excessive collagen formation during the healing that extends beyond the site of the original injury. A rough, thickened, hardened area of epidermis resulting from chronic irritation keloid- ear pierce lichenification- chronic dermatitis (scratching) Rubella (German Measles) A highly contagious viral disease, especially affecting children, that causes swelling of the lymph glands and a reddish pink rash Rubeola a highly contagious viral disease that causes a rash of red and purple macule or papule Varicella (chicken pox) Viral disease (varicella zoster) characterized by small, red, fluid filled vesicles lesions begin on the trunk and spread to the face and proximal extremities herpes simplex Recurring viral infection that often presents as a fever blister or cold sore. herpes zoster (shingles) reactivation of latent varicella zoster virus clusters of small vesicles form along the sensory nerves contact dermatitis irritated or allergic response of the skin that can lead to an acute or chronic inflammation eczema inflammation of skin causing reddened papule and vesicles that ooze and weep and possibly crust Psoriasis thickening of the skin in dry, silvery, scaly patches due to overproduction of skin cells malignant melanoma The least common but most deadly type of skin cancer because is spreads rapidly to lymph and blood vessels Aloepecia hair loss hirsutism excessive hair growth on females following the male pattern due to endocrine or metabolic dysfunction Causes of skin cancer UV rays, change in moles or birthmarks, sunburns/sunburnt easily Tattoos may lead to... infection or irritation Piercings may lead to... infection and hepatitis C Patients with anxiety may experience... Pallor and diaphoresis Nurses should acknowledge the problem Urea and ammonia salts are found... on the skin of patients with kidney disorders Higher temperature of skin can mean what? Infection Hyperthyroidism Exercise Environment Lower temperature of skin can mean what? Hypothyroidism Environment Decreased circulation Bilateral temperature findings mean Hot on one side of the body: inflammation Cold on one side of the body: compression, immobilization, elevation When does diaphoresis occur? exertion fever pain stress hyperthyroidism MI Dry skin means? It is dark, weathered and fissured Pruritus (scratching)- abrasion- thickening Dehydration Hypothyroidism Lower legs: vascular insufficiency Increased skin turgor means? caused by scleroderma (hard skin)- scarred or immobile Ecchymosis (bruise) periumbilical= bleeding in abdomen flank area= pancreatitis or bleeding in peritoneum What results in the injection of drugs into the veins of the arms? track marks Nurse should suspect substance abuse and refer patient to a mental health/ substance abuse professional Graying of the hair means what? nutritional deficit of copper and protein Those who have hypothyroidism will have hair that is.... dull, dry, brittle, and coarse Hair loss in women can mean.... an imbalance of adrenal hormones Gray, scaly patches with broken hair may indicate.... fungal infection like ringworm pediculosis infestation with lice Cranium bones are connected by? sutures Jerky movements could indicate? neurologic or psychologic disorders Bruit indicative of stenosis (narrowing) of the vessel crepitation or crepitus crackling sound on movement; may indicate joint problems Excessive rigidity of the neck may indicate arthritis Inability to hold the neck erect may be due to muscle spasms Swelling of the lymph nodes may indicate an infection What causes dizziness? rapid movement and compression of the cerebral vertebrae Palpating the trachea may be difficult for what age group? 3 years and under because their necks are short and thick Hyperthyroidism is caused by what during pregnancy? Graves' disease slightly enlarged thyroid is normal Hyperthyroidism subjective findings irritability/nervousness muscle weakness/ fatigue insomnia heat intolerance amenorrhea Hyperthyroidism objective findings thyroid gland enlargement exophthalmos (bulging eyes) cardiac changes 100 bpm skin thinning brittle hair weight loss diaphoresis Hypothyroidism subjective findings weakness/tired depression heavy menstrual periods difficulty concentrating cold intolerance Hypothyroidism objective findings constipation dry skin and weak nails weight gain cool skin systemic lupus erythematosus (SLE) autoimmune disease in which immune system attacks connective tissue throughout body such as in joints and skin causing inflammation Bell's Palsy Etiology affects cranial nerv VII (facial paralysis Caused by a virus Chronic temporomandibular joint syndrome (TMJ) trigger injury to teeth or jaw misalignment of the teeth or jaw, teeth grinding or clenching, poor posture, stress, arthritis, and gum chewing. Parkinson's disease bradykinesia slowlike movement, rigidity, masklike expression (bradykinesia used for diagnosis of Parkinson's) caused by decrease in the production of dopamine What is the first and last phase of Korotkoff's sounds heard on auscultation? systolic/diastolic (phase 4 is diastolic in children) Edema +1 - 2mm +2 -4mm +3 - 6mm +4 - 8mm on inspection of a pressure ulcer, you see intact skin and document what? stage 1 on inspection of a pressure ulcer, you see into the epidermal skin layer and document what? stage 2 on inspection of a pressure ulcer, you see subcutaneous tissue and document what? stage 3 on inspection of a pressure ulcer, you see bone and muscle, what do you document? stage 4 you see a nurse palpating with thumb and index finger and know they are palpating what? lesions you are see a preceptor nurse educating a student nurse on Asymmetry, border irregularity, color variation, diameter 6mm and evolving changes. you know this is used for? cancerous lesions you are looking at a previous shifts notes as you begin your shift and see a note that reads "pediculosis capitis" you know this means? head lice on inspection of a baby, you see small white spots on their face and document milia, you tell the parents not to worry because? it will go away in a few weeks on inspection on a child, you see muscular blue gray pigmentation on their sacral area and document MONGOLIAN SPOTS, the parents are worried, how would you calm their nerves? "These spots disappear after years of age" you notice small itchy vesicles along a nerve route on a younger patient and document? herpes zoster you notice a progression of vesicles to pustules and then crust and document what? herpes simplex on inspection you notice red to purple macules, oral mucosa with white spots on a patient with rubeola (measles), what do you document? Koplik Spots When seeing a patient you see pink, swollen glands and a rash on their face, what do you suspect? Rubella (germen measles) you see dry blood, serum or pus on a patient and document what? crust you notice elevated, irregular, darkened area of extra scar tissue with excessive collagen formation (common in African American teens), you document what? keloid what is trauma or an infeciton of the nails? onycholysis Impaired peripheral tissue perfusion 160-degree angle means long term hypoxia; you have the patient do the shamroth technique(diamond) to diagnose. what do you document? clubbing (160 normal) on inspection you see an elevated solid palpable mass with a circumscribed border and document what? papule and plaque on inspection you see an elevated fluid filled round or oval sac that is palpable and document what? Vesicle and Bulla you notice a flat change in skin color that is not palpable and document what? macule and patch you notice an elevated puss filled vesicle and document what? Pustule you notice an insect bite that is elevated and reddish with an irregular border and document what? wheal you notice an elevated encapsulated fluid filled area on a patient's body and document what? cyst A patient bruised herself and caused a flat, irregular shape on their skin, you document what? ecchymosis After labor a mother notices an area on their baby that is bright red, the nurse ensures the mother that it will disappear by age 10, what is this? Hemangioma what seems to be ecchymosis on a patient is slightly elevated, what does the nurse suspect? ecchymosis you see flat, red or purple round freckles and know this is? petechiae at birth of baby, you see a pale red to purple red flat irregular shape on a baby, you know this is a PORT WINE STAIN and wont what? fade a patient with a fungal infection comes into the clinic and needs a skin assessment, what tool will you use? woods lamp you muse measures the thickness of body fat on patient, so you use this tool? skinfold calipers you muse measures the degree of joint flexion and extension on a patient so you must use this tool? Goniometer circular shape annular concentric circles of color target appears in clusters grouped circular but united polycyclic twisted or coil gyrate linear manner along nerve route zosteriform lesions that run together confluent