Nursing Fundamentals keiser university Exam Questions With Complete Answers.

Exam 2 Nursing Fundamentals keiser university *What are the purposes of a physical examination:* - ✔✔ • To collect baseline data • Verify data obtained in nursing history • Obtain data to establish plan of care • Make clinical judgments about client's health status. • Provide teaching • Identify areas for health promotion and disease prevention A physical examination can be any of the three types: - ✔✔ • *A comple te assessment* (ie. when a patient is admitted to a health care facility • *Examination of body system* (ie. cardiovascular system) • *Examination of a body area* (ie. the lungs, when difficulty with breathing is observed) *the procedure can vary accor ding to age of individual, the severity of the illness, preference of the nurse, location of the examination, and the facilities priorities and procedures *The health assessment is performed in a systematic and efficient manner that results in the fewest position changes for the patient - ✔✔ *Techniques of a physical examination:^ - ✔✔ Inspection Percussion Palpation Auscultation *For Abdomen:* Inspection Auscultation Percussion Palpation How do we document the findings for the physical examination? - ✔✔ *Edema* - ✔✔ = presence of excess interstitial fluid (area appears swollen, shiny • blanches the skin color • if accompanied by inflammation, may redden the skin = generally caused by impai red venous circulation. Scale for grading edema: 1+=2mm; 2+=4mm; 3+=6mm; 4+=8mm. observe and palpate *Skin turgor* - ✔✔ Check for fullness or elasticity • lift and pinch the skin on an extremity or on the sternum. • If skin stays pinched or tented mean s dehydration. Count how long in seconds and document. *Nails* inspected for: - ✔✔ *clubbing* = the angle between the nail and nail bed is 180 degrees or greater = caused by long -term *lack of oxygen* *spoon -shaped nail* = the nail curves upward =*(koilonychia)* patients with *iron deficiency anemia* *Beau's line* = result from severe injury or illness *a normal nail is convex in shape with a nail plate angle of about 160 degrees Blanch test = - ✔✔ tests capillary refill, peripheral circulation Paronychia = - ✔✔ an inflammation of the tissues surrounding a nail (ingrown nail) What terms are included in the general assessment: - ✔✔ • Signs of distress • Health, stature, sexual development • Weight, heig ht, vital signs • Posture, motor activity, gait • Dress, grooming, personal hygiene • Facial expressions and behaviors • Reactions to persons and environment • Quality of speech and level of consciousness Routine exams and how often they should be done: *Breast exam* *Prostate exam to be done early starting at the age of 40 -45 - ✔✔ Guideline for *breast* self Examination