WTCC NUR 111 Lab Exam 1 Questions with 100% Correct Answers | Verified | Latest Update 2024

Purpose of physical assessment - ANSgather baseline data Purpose of physical assessment - ANSsupport/refute (validate) subjective data Purpose of physical assessment - ANSidentify/confirm nursing dx Purpose of physical assessment - ANSreassess Purpose of physical assessment - ANSevaluate the outcome of care a criteria for an effective physical examination environment - ANSprivacy criteria for an effective physical examination environment - ANSadequate lighting criteria for an effective physical examination environment - ANSexam table criteria for an effective physical examination environment - ANSquite criteria for an effective physical examination environment - ANScomfortable patient criteria for an effective physical examination environment - ANSinfection control precautions criteria for an effective physical examination environment - ANSkeep yourself safe criteria for an effective physical examination environment - ANShave equipment available criteria for an effective physical examination environment - ANSminimize pt. position changes one of 5 items needed when preforming a basic assessment - ANSstethoscope one of 5 items needed when preforming a basic assessment - ANSpen light one of 5 items needed when preforming a basic assessment - ANSwatch one of 5 items needed when preforming a basic assessment - ANSdrape one of 5 items needed when preforming a basic assessment - ANSgloves aspect of general survey: general appearance and behavior - ANSi. Gender & race, signs of distress, hygiene, nonverbal behaviors, posture, mood, speech, signs of injuries/abuse not consistent w/records aspect of general survey: vital signs - ANSdone before position change, asses pain at this time, provide overview of pt's status and can ID abnormalities aspect of general survey:height and weight - ANSreflects general health status, assess for health growth, development in babies and children, ID nutrition defects in elderly Inspection - ANS- looking for wounds, see improvement/decline, evidence of neglect, Environmental safety Palpation - ANStouching, using fingertips or back of hand to assess, can assess skin temp, moisture, blanching, edema, thickness, pain level, turgor, can assess abdomen whether hard/soft, shape, masses, distention, can assess fontanels of a baby Percussion - ANStouching, using fingertips or back of hand to assess, can assess skin temp, moisture, blanching, edema, thickness, pain level, turgor, can assess abdomen whether hard/soft, shape, masses, distention, can assess fontanels of a baby Auscultation - ANSlistening to sounds body makes, usually w/stethoscope, diaphragm best for high pitch sounds (bowels, breath, normal heart sounds), bell better for low pitch sounds (murmurs, extra heart sounds) Olfaction - ANSusing the sense of smell to detect abnormalities that go unrecognized head to toe assessment - ANSa full assessment of all body systems, used upon admission usually, and during an annual physical assessment focused assessment - ANSmore specific , focuses on problem at hand per the patient complaint, used often in acute situations and in ER, more narrow assessment developmental considerations with children - ANSget down on child's level; consider their developmental achievement to that point. With young toddlers, build trust w/the parent first and the child will see that & be more willing to interact w/you. With older toddlers, may need to show them how you are going to perform a technique, let them explore the equipment when you can, be honest w/them. developmental considerations with adolescents - ANStreat them as individuals/adults, make them aware and a part of their treatment and be honest. They have a right to confidentiality & you can speak w/them alone after discussing historical info w/them & the parents. developmental considerations with young adults - ANSassess ADLs, relationships, religious pursuits developmental considerations with older adults - ANSdo not stereotype about their level of cognition, give time to answer questions, take into consideration some sensory deficits they may have, be aware of closest bathroom in the event of urgency normal pulse range for infants - ANS120-160 normal pulse range for school aged children - ANS60-100 normal pulse range for adults - ANS60-100 pulse range 0 - ANSabsent, not palpable pulse range 1+ - ANSpulse diminished, barely palpable pulse range 2+ - ANSexpected/normal pulse range 3+ - ANSfull pulse, increased pluse range 4+ - ANSbounding pulse normal respiration rate for teens and adults - ANS12-20 breaths normal vesicular sounds - ANSsoft, low pitch inspirations heard the longest, 3:1 normal bronchovesicular sounds - ANSinspiration and expiration sounds are even, 1:1 normal bronchial sounds - ANSexpiration heard the longest, 2:3 crackles - ANSabnormal breath sound, high pitched, head at end of inspiration, not cleared by cough rhonci - ANSabnormal breath sound, head over trachea, loud, low pitched, sometimes cleared by cough wheezes - ANSabnormal breath sound, heard over all lung fields, high pitched, continuous musical sound, usually louder on expiration pleural friction rub - ANSabnormal breath sound, over anterior lateral lung, dry, rubbing quality heard during inspiration and expiration, not cleared by coughing normal BP for adults - ANS120/80 S1 - ANSLub sound, heard best at PMI/apex of heart, mitral and tricuspid valves close, ventricles contract, systole systole - ANSventricles are contracting, Lub sound S2 - ANSDub sound, heard best at base of heart or 2nd intercostal space, aortic and pulmonic spaces, valves close, ventricles relax and refill, diastole diastole - ANSventricles fill, Dub sound heard S3 - ANScommon in children/young adults, lub dub-bee S4 - ANSheard before s1, pathological in adults TEN-nes-see murmur - ANSturbulent blood flow bruit - ANSmurmur in blood vessel, usually in carotid thrill - ANSpalpable murmur sinus arrhythmia - ANSwhen lub/dub speeds up with respirations vascular abnormality cue - ANSlack of hair vascular abnormality cue - ANSbad toe nails vascular abnormality cue - ANSlack of good blood return, marked with swelling, pink, red/brown color