Ch13 Physical Assessment

Podcast Beta

Play an AI-generated podcast conversation about this lesson

Questions and Answers

Where does the nurse begin a head-to-toe assessment?

Neurologic assessment (correct)

Respiratory assessment

Circulatory assessment

Skin assessment

What indicates decreased skin turgor in an older adult patient?

Swelling in the skin

Rapid return of skin after being grasped

Coloration changes in skin

Slow return of skin after being grasped (correct)

When are crackles most often heard during a physical assessment?

Following expiration

Following inspiration

During inspiration (correct)

During expiration

What physiological change causes the 'lub' sound during heart auscultation?

Closing of the AV valves Signup and view all the answers

What condition is primarily responsible for decreased skin turgor?

Dehydration Signup and view all the answers

During a physical assessment, adventitious lung sounds are checked. What are crackles classified by?

Timing of occurrence Signup and view all the answers

What type of assessment method involves examining the body systematically from head to toe?

Head-to-toe assessment Signup and view all the answers

In which phase of respiration are crackles generally heard?

During inspiration Signup and view all the answers

Which heart valves closing primarily contributes to the 'dup' sound on auscultation?

Pulmonary valves Signup and view all the answers

What is the heart condition characterized by a heart rate of less than 60 contractions per minute called?

Bradycardia Signup and view all the answers

What condition is indicated by a bluish discoloration of the skin and mucous membranes?

Cyanosis Signup and view all the answers

Which term describes discoloration due to the extravasation of blood into subcutaneous tissues?

Ecchymosis Signup and view all the answers

What do you call the redness or inflammation that results from the congestion of superficial capillaries?

Erythema Signup and view all the answers

Which of the following conditions is characterized by increased fragility of blood vessel walls?

Ecchymosis Signup and view all the answers

What cardiovascular condition is primarily assessed by monitoring heart rate?

Bradycardia Signup and view all the answers

What does the 'R' stand for in the PQRST system used for patient history intake?

Region Signup and view all the answers

Which method is particularly useful for detecting tenderness or masses during a physical examination?

Deep palpation Signup and view all the answers

When auscultating breath sounds, which sound is low-pitched, coarse, and has a gurgling quality?

Sonorous wheezes Signup and view all the answers

What does the density of underlying tissue indicate during a physical assessment?

Breath sound characteristics Signup and view all the answers

Which of the following methods of examination is least likely to be used to assess tenderness in the abdomen?

Auscultation Signup and view all the answers

Which technique would be the most appropriate for examining a patient with known respiratory issues?

Auscultating Signup and view all the answers

What is typically the first step in a systematic approach to auscultating the thorax?

Apices Signup and view all the answers

Which of the following is NOT characteristic of sonorous wheezes?

High-pitched Signup and view all the answers

In performing physical assessments, which finding would lead a nurse to suspect mucus presence in a patient's airways?

Sonorous wheezes Signup and view all the answers

Which of the following actions would be least effective when assessing a patient's abdomen for tenderness?

Listening for bowel sounds Signup and view all the answers

What is indicated by a unilateral, dilated, and nonreactive pupil during a neurologic assessment?

Pressure on cranial nerve III Signup and view all the answers

Which position is optimal for inserting a vaginal speculum during an examination?

Lithotomy position Signup and view all the answers

In which position should the nurse place the patient to assess extension of the hip joint?

Prone position Signup and view all the answers

What is the recommended position for assessing a patient for a heart murmur?

Supine position Signup and view all the answers

What is the appropriate documentation when a nurse observes a patient experiencing a sudden audible expulsion of air from the lungs?

Coughing Signup and view all the answers

What should the nurse document if a patient has profuse secretions of sweat?

Diaphoresis Signup and view all the answers

What is the primary function of cranial nerve III?

Eye movement control Signup and view all the answers

During a physical assessment, frequent loose liquid stools indicate that a patient is experiencing what condition?

Diarrhea Signup and view all the answers

Which of the following nerves is affected by increased intracranial pressure resulting in a nonreactive pupil?

Cranial nerve III Signup and view all the answers

What finding during a neurologic assessment suggests possible involvement of the oculomotor nerve?

Unilateral pupil dilation Signup and view all the answers

Which term describes the protective response that clears the lungs of irritants?

Coughing Signup and view all the answers

What condition might be indicated by dark black, tarry stools in a patient?

Internal bleeding Signup and view all the answers

Which position maximally exposes the genitalia for a vaginal examination?

Lithotomy position Signup and view all the answers

Which of the following is NOT an objective finding that a nurse might document during an assessment?

Subjective pain report Signup and view all the answers

What is the priority nursing action when a patient has a nonreactive pupil?

Notify the physician Signup and view all the answers

What is the most appropriate action if a patient becomes unresponsive with fixed dilated pupils?

Call for emergency assistance Signup and view all the answers

A patient exhibits symptoms of excessive sweating during an assessment. What should be the nurse's documentation?

Diaphoresis Signup and view all the answers

Which of the following terms relates to the clinical assessment of a patient's respiratory distress?

Dyspnea Signup and view all the answers

What should a nurse assess if a patient presents with symptoms of mental or emotional stress and sweating?

Diaphoresis Signup and view all the answers

Frequent loose liquid stools can result from which of the following?

Increased motility in the intestines Signup and view all the answers

Study Notes

Head-to-toe Assessment

When performing a head-to-toe assessment, the nurse begins with a neurologic assessment
Nursing Assessment is a crucial step within the nursing process

Skin Assessment

Dehydration results in decreased skin turgor, which is assessed when the skin is grasped and raised, then observed for its return to the previous position.

Lung Sounds

Crackles, which are classified as fine, medium, or coarse, are usually heard during inspiration.

Heart Sounds

Auscultating the heart sounds with a stethoscope should result in a "lub-dup" sound.
The "lub" sound is caused by the closing of the AV valves.

PQRST

The PQRST system is used for the interview assessment
The R in the PQRST system stands for "region"

Abdominal Examination

Deep palpation is used to detect tenderness or masses in the abdomen

Breath Sounds

Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.

Neurologic Assessment

A unilateral, dilated, and nonreactive pupil is a sign of pressure on the oculomotor nerve (cranial nerve III)

Patient Positioning

The lithotomy position facilitates the insertion of a vaginal speculum
The prone position is used to assess extension of a patient’s hip joint.

Physical Assessment Terminology

A sudden audible expulsion of air from the lungs is classified as coughing
Profuse secretions of sweat are referred to as diaphoresis
Frequent passage of loose liquid stools are classified as diarrhea
Bradycardia is a heart rate of less than 60 beats per minute
Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood
Ecchymosis is discoloration of the skin or mucous membrane caused by blood leaking into the subcutaneous tissues
Erythema is redness or inflammation of the skin or mucous membranes caused by dilated and congested superficial capillaries

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

This quiz covers essential techniques for head-to-toe assessments in nursing, including skin evaluation, lung and heart sound auscultation, and abdominal examination methods. It also highlights critical assessment systems used in nursing practice. Test your knowledge on these fundamental clinical skills.

Ch13 Physical Assessment

Podcast Beta

Questions and Answers

Where does the nurse begin a head-to-toe assessment?

What indicates decreased skin turgor in an older adult patient?

When are crackles most often heard during a physical assessment?

What physiological change causes the 'lub' sound during heart auscultation?

What condition is primarily responsible for decreased skin turgor?

During a physical assessment, adventitious lung sounds are checked. What are crackles classified by?

What type of assessment method involves examining the body systematically from head to toe?

In which phase of respiration are crackles generally heard?

Which heart valves closing primarily contributes to the 'dup' sound on auscultation?

What is the heart condition characterized by a heart rate of less than 60 contractions per minute called?

What condition is indicated by a bluish discoloration of the skin and mucous membranes?

Which term describes discoloration due to the extravasation of blood into subcutaneous tissues?

What do you call the redness or inflammation that results from the congestion of superficial capillaries?

Which of the following conditions is characterized by increased fragility of blood vessel walls?

What cardiovascular condition is primarily assessed by monitoring heart rate?

What does the 'R' stand for in the PQRST system used for patient history intake?

Which method is particularly useful for detecting tenderness or masses during a physical examination?

When auscultating breath sounds, which sound is low-pitched, coarse, and has a gurgling quality?

What does the density of underlying tissue indicate during a physical assessment?

Which of the following methods of examination is least likely to be used to assess tenderness in the abdomen?

Which technique would be the most appropriate for examining a patient with known respiratory issues?

What is typically the first step in a systematic approach to auscultating the thorax?

Which of the following is NOT characteristic of sonorous wheezes?

In performing physical assessments, which finding would lead a nurse to suspect mucus presence in a patient's airways?

Which of the following actions would be least effective when assessing a patient's abdomen for tenderness?

What is indicated by a unilateral, dilated, and nonreactive pupil during a neurologic assessment?

Which position is optimal for inserting a vaginal speculum during an examination?

In which position should the nurse place the patient to assess extension of the hip joint?

What is the recommended position for assessing a patient for a heart murmur?

What is the appropriate documentation when a nurse observes a patient experiencing a sudden audible expulsion of air from the lungs?

What should the nurse document if a patient has profuse secretions of sweat?

What is the primary function of cranial nerve III?

During a physical assessment, frequent loose liquid stools indicate that a patient is experiencing what condition?

Which of the following nerves is affected by increased intracranial pressure resulting in a nonreactive pupil?

What finding during a neurologic assessment suggests possible involvement of the oculomotor nerve?

Which term describes the protective response that clears the lungs of irritants?

What condition might be indicated by dark black, tarry stools in a patient?

Which position maximally exposes the genitalia for a vaginal examination?

Which of the following is NOT an objective finding that a nurse might document during an assessment?

What is the priority nursing action when a patient has a nonreactive pupil?

What is the most appropriate action if a patient becomes unresponsive with fixed dilated pupils?

A patient exhibits symptoms of excessive sweating during an assessment. What should be the nurse's documentation?

Which of the following terms relates to the clinical assessment of a patient's respiratory distress?

What should a nurse assess if a patient presents with symptoms of mental or emotional stress and sweating?

Frequent loose liquid stools can result from which of the following?

Study Notes

Head-to-toe Assessment

Skin Assessment

Lung Sounds

Heart Sounds

PQRST

Abdominal Examination

Breath Sounds

Neurologic Assessment

Patient Positioning

Physical Assessment Terminology

Studying That Suits You

Related Documents

Description

More Like This

Nursing Assessment Review Quiz

Nursing Application Exercises

Registered Nursing Health Assessments Quiz