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In which order would the nurse perform an assessment of the integumentary system.
Interview the patient to complete the general survey, health history, and review of systems. = 2 Complete physical examination of the skin, hair, and nails. = 3 Review the patient’s medical records for preexisting issues with skin, hair, or nails. = 1
Which components would the nurse assess during palpation of the skin?
Which part of the eye would the nurse palpate gently to assess for nodules or pain?
Which techniques would the nurse utilize to auscultate the patient’s chest during the respiratory assessment?
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Which aspects does the nurse assess while palpating the chest during the respiratory system assessment?
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Which characteristic is the nurse assessing when placing thumbs on either side of the spine during the respiratory system assessment?
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Which actions would the nurse implement during auscultation of the cardiovascular system?
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Which action allows the nurse to focus questions about the musculoskeletal system during the health history interview?
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Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination?
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Which assessment technique would the nurse use during the neurologic assessment?
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Which assessment techniques would the nurse use during the abdominal assessment?
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Which findings would the nurse recognize as abnormal during assessment of the male genitalia?
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When the nurse identifies clubbing of a patient’s nails, which type of medical condition would the nurse suspect as the cause?
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Which part of the nose would the nurse palpate to assess for swelling, drainage, and tenderness?
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When examining the head and its associated structures, which unexpected findings would the nurse document?
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Which additional body system would the nurse evaluate when assessing the cardiovascular and peripheral vascular systems?
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Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities?
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Which physical assessment findings related to the musculoskeletal system would the nurse report to the health care provider?
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Which nerve does the nurse assess when applying dull and sharp stimuli to different areas of the body?
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Which nerve does the nurse examine by evaluating eye movements and pupillary reflexes?
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The abdominal and gastrointestinal organs are assessed during the evaluation of which body systems?
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Which component of the gastrointestinal assessment does the nurse evaluate using the diaphragm of the stethoscope?
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Which technique would the nurse use to palpate the breast tissue?
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During the breast and genital examination, which findings would the nurse document and report to the health care provider?
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Study Notes
Integumentary System Assessment Order
- Inspection: Visual examination of the skin, hair, and nails
- Palpation: Feeling the skin for texture, temperature, moisture, and any abnormalities
- Auscultation: Listening for sounds, which is not typically performed during a routine integumentary assessment
Integumentary System Palpation
- Texture: Smoothness, roughness, or any lesions
- Temperature: Warmth, coolness, or areas of increased warmth or coolness
- Moisture: Dryness, oiliness, or excessive sweating
- Turgor: Elasticity of the skin, which reflects hydration status
Eye Examination
- Palpation: Gently palpate the eyelids for nodules or pain, focusing on the lacrimal gland area
Respiratory System Auscultation Techniques
- Diaphragm of the stethoscope: Used for listening to breath sounds, especially in the lung bases
- Bell of the stethoscope: Useful for identifying low-pitched sounds like murmurs or heart sounds
Respiratory System Palpation
- Chest expansion: Assessing the symmetry of chest wall movement during inspiration and expiration
- Tactile fremitus: Vibrations felt on the chest wall during speech, which can indicate lung consolidation or fluid
Respiratory System Assessment
- Thumb Placement: Placing thumbs on either side of the spine to assess the symmetry and depth of chest expansion during breathing
Cardiovascular System Auscultation
- Auscultate heart sounds: Listening to the heart sounds at four key locations on the chest using the diaphragm and bell of the stethoscope
- Auscultate carotid arteries: Listening to the carotid arteries for bruits, which indicate turbulent blood flow
- Auscultate abdominal aorta: Listening for bruits, which can indicate an aneurysm or narrowing of the aorta
Musculoskeletal System Health History Questions
- Focus on: Joint pain, stiffness, swelling, deformities, decreased range of motion, muscle weakness, and any history of injuries or surgeries
Musculoskeletal System Palpation
- Palpate joints: Checking for tenderness, swelling, warmth, and crepitus
- Palpate muscles: Assessing for tenderness, spasms, and atrophy
Neurologic Assessment Techniques
- Mental status: Assessing the patient's level of consciousness, orientation, memory, and judgment
- Cranial nerves: Evaluating the function of each cranial nerve using specific tests
- Motor function: Testing muscle strength and coordination
- Sensory function: Assessing the patient's ability to feel different sensations like light touch, pain, and temperature
- Reflexes: Evaluating the deep tendon reflexes using a reflex hammer
Abdominal Assessment Techniques
- Inspection: Observing the abdomen for distention, masses, scars, striae, and any unusual movements
- Auscultation: Listening for bowel sounds in all four quadrants of the abdomen
- Palpation: Gently palpating the abdomen to assess for tenderness, guarding, masses, and organ enlargement
- Percussion: Tapping on the abdomen to assess the density of the underlying structures
Abnormal Male Genitalia Findings
- Testicular pain or swelling: May indicate infection, trauma, or a tumor
- Inguinal hernia: A bulge in the groin area that may cause pain or discomfort
- Discharge from the penis: Can be a sign of a sexually transmitted infection (STI)
Clubbing of the Nails
- Clubbing: A condition in which the fingertips and nail beds become enlarged and thickened, often associated with chronic lung diseases, such as cystic fibrosis, bronchiectasis, and lung cancer
Nose Palpation
- Palpate the nasal bridge: Feeling for any swelling, tenderness, or drainage
Unexpected Head and Neck Findings
- Swelling or masses: Can be caused by infections, trauma, or tumors
- Abnormal lymph node enlargement: May indicate an infection or other underlying medical condition
- Limited range of motion: Can result from muscle strain, arthritis, or neck injury
Cardiovascular and Peripheral Vascular Systems
- Evaluate the lungs: Assessing lung sounds for crackles, wheezes, or other abnormal sounds that might indicate heart failure or pulmonary hypertension
Lower Extremities Inspection
- Skin: Checking for discoloration, edema, and ulcers, which can be signs of poor circulation
Musculoskeletal Findings to Report
- Joint pain that is severe or persistent: May indicate arthritis, infection, or injury
- Muscle weakness or atrophy: Suggestive of nerve damage or muscle disease
- Deformities or limitations in range of motion: Could be due to trauma, arthritis, or other conditions
Sharp and Dull Stimuli Assessment
- Spinal Cord: Assessing the integrity of the spinal cord by evaluating the patient's ability to distinguish between sharp and dull stimuli
Eye Movement and Pupillary Reflexes
- Cranial Nerve III (Oculomotor): Checking for eye movements, pupillary reflexes, and eyelid drooping
Gastrointestinal Assessment Systems
- Gastrointestinal system: Involves assessment of the abdomen and associated organs such as the stomach, intestines, liver, and pancreas
Auscultation of Bowel Sounds
- Diaphragm: Used to listen for bowel sounds in different quadrants of the abdomen
Breast Tissue Palpation
- Bimanual palpation: Using both hands to feel the breast tissue for any lumps, nodules, or other abnormalities
Breast and Genital Findings
- Any abnormalities in breast tissue: Lumps, masses, tenderness, or nipple discharge
- Any abnormalities in the genitalia: Discharge, lesions, or swelling
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Description
Test your knowledge on the proper order of assessment for the integumentary system. This quiz covers key concepts that nurses must know while evaluating skin, hair, and nails. Challenge yourself and see how well you understand this critical nursing procedure.
