Physical Assessment Techniques

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Questions and Answers

What aspect of a client's appearance could potentially indicate a hormonal change?

  • Hair distribution (correct)
  • Facial expression
  • Nail texture
  • Skin color

What is NOT a potential indicator of a musculoskeletal problem?

  • Bent posture
  • Erect posture
  • Skin lesions (correct)
  • Slumped posture

What is mentioned as a factor that must be ruled out when assessing a client's weight?

  • Muscle mass
  • Nutritional deficiencies
  • Bone density
  • Fluid retention (correct)

Why is it important to assess a client's level of consciousness?

<p>To gauge their ability to cooperate (D)</p> Signup and view all the answers

What is the primary purpose of examining a client's gait?

<p>To assess their musculoskeletal alignment (B)</p> Signup and view all the answers

What is the significance of a client's verbal and nonverbal expressions matching during an assessment?

<p>It indicates that the client is responding appropriately to the situation (D)</p> Signup and view all the answers

What is the primary purpose of assessing a client's vital signs?

<p>To evaluate their overall health (A)</p> Signup and view all the answers

What is NOT a component of the head assessment?

<p>Checking the client's height (C)</p> Signup and view all the answers

What color is dry cerumen?

<p>Grayish-Tan (D)</p> Signup and view all the answers

What could indicate habitual use of intranasal cocaine and opioids?

<p>All of the above (D)</p> Signup and view all the answers

What is the purpose of palpatation of the maxillary and frontal sinuses?

<p>To assess the presence of tenderness (D)</p> Signup and view all the answers

What can be observed when inspecting the teeth?

<p>All of the above (D)</p> Signup and view all the answers

What is the purpose of inspecting the external ear canal?

<p>All of the above (D)</p> Signup and view all the answers

What could indicate an allergy or infection of the nose?

<p>Discharge from the nose (D)</p> Signup and view all the answers

What does the color brown or black in lesions indicate?

<p>Previous trauma (B)</p> Signup and view all the answers

What is the purpose of palpating the external nose?

<p>All of the above (D)</p> Signup and view all the answers

What is the primary reason for positioning the client sitting upright during thoracic assessment?

<p>To promote full lung expansion (A)</p> Signup and view all the answers

What should the nurse assess regarding tobacco use in a client with respiratory alterations?

<p>The client's smoking history, including pack-years and duration of quitting (D)</p> Signup and view all the answers

What is a key aspect to assess during the thoracic assessment?

<p>All of the above (D)</p> Signup and view all the answers

What should the nurse observe when assessing for retractions in the intercostal spaces during a thoracic assessment?

<p>Indentation of the spaces during inhalation (C)</p> Signup and view all the answers

When assessing tobacco use, what is considered a significant factor in evaluating a client's respiratory status?

<p>The number of pack-years smoked (D)</p> Signup and view all the answers

What aspect of the eyes is assessed by noting the color of the inner parts of the lower eyelids?

<p>Conjunctiva (A)</p> Signup and view all the answers

Which of the following is NOT a characteristic of normal pupils?

<p>Unequal in size (C)</p> Signup and view all the answers

What does the assessment of visual acuity aim to determine?

<p>Ability to see both near and far objects (B)</p> Signup and view all the answers

When testing papillary reflexes, what is the purpose of dimming the room lights?

<p>To ensure brisk response of the pupils to light (B)</p> Signup and view all the answers

What action should be taken if a client has obvious hearing impairment during the assessment?

<p>Speak slowly and clearly (D)</p> Signup and view all the answers

What physical characteristic is associated with low-set ears?

<p>Down syndrome (A)</p> Signup and view all the answers

Which of the following is NOT a component of a head and neck assessment?

<p>Assessing the client's gait (D)</p> Signup and view all the answers

What is the term used to describe the condition of excessive tearing?

<p>Epiphora (B)</p> Signup and view all the answers

What tool is used to aid in the visualization of the oropharynx?

<p>Tongue depressor (B)</p> Signup and view all the answers

What is the client asked to do to allow for proper visualization of the uvula?

<p>Say &quot;ahh&quot; (C)</p> Signup and view all the answers

What features of the tonsils are assessed?

<p>Size, color, and discharge (B)</p> Signup and view all the answers

Which of the following is NOT assessed during inspection of the oropharynx?

<p>Movement (C)</p> Signup and view all the answers

What is the purpose of asking the client to extend their neck and then swallow?

<p>Observe how the thyroid cartilage moves (D)</p> Signup and view all the answers

When palpating the thyroid gland, which fingers are used?

<p>Index and middle finger (D)</p> Signup and view all the answers

What is one way to help improve visualization of the thyroid gland?

<p>Asking the client to tilt their head back (A)</p> Signup and view all the answers

During palpation of the thyroid gland, what is one thing to pay attention to?

<p>The presence of masses or nodules (B)</p> Signup and view all the answers

What is the primary purpose of conducting a physical assessment?

<p>To obtain baseline data about the client's functional abilities (A)</p> Signup and view all the answers

Which method of examination involves using the sense of touch?

<p>Palpation (C)</p> Signup and view all the answers

Why is it important to prepare the environment before conducting a physical assessment?

<p>To ensure client comfort and prevent chilling (D)</p> Signup and view all the answers

Which piece of equipment is essential for measuring body temperature during a physical assessment?

<p>Thermometer (C)</p> Signup and view all the answers

What is the purpose of percussion in a physical assessment?

<p>To evaluate the size and consistency of body organs (C)</p> Signup and view all the answers

Which practice helps to reduce the transmission of microorganisms during a physical assessment?

<p>Washing hands (C)</p> Signup and view all the answers

When conducting a general survey during a physical assessment, which of the following aspects is NOT typically noted?

<p>Family medical history (A)</p> Signup and view all the answers

Which of the following is NOT a method of examination used in physical assessments?

<p>Diagnosis (B)</p> Signup and view all the answers

Flashcards

Hair Assessment

Evaluate hair's mass, condition, distribution, and signs of dandruff or lice.

Palpation of Head

Examine head for deformities or swelling through touch.

Eye Inspection

Check eye position, color, and changes like redness or swelling.

Pupil Reaction

Assess pupil size, shape, and how they react to light.

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Visual Acuity Testing

Determine clarity of vision by reading near and far texts.

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Papillary Reflex Test

Test pupil constriction reaction to light in a dark room.

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Ear Assessment

Observe ear for color, symmetry, and position relative to eyes.

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Hearing Evaluation

Notice client's hearing ability and response to sound.

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Posture Assessment

Evaluating alignment of shoulders and hips during standing and sitting.

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Skin Changes

Alterations in skin color or lesions can indicate health issues.

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Hair Inspection

Assessing hair distribution, thickness, and texture for health indicators.

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Nail Examination

Observation of nails for nutrition, grooming, or disease signals.

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Weight Assessment

Monitoring sudden weight changes to assess health or fat levels.

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Vital Signs Check

Evaluating temperature, pulse, respiration, and blood pressure for physiological status.

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Mood and Affect Evaluation

Checking if verbal/nonverbal cues match the client's emotional state.

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OtoScope Inspection

Use an otoScope to check the external ear for cerumen, lesions, pus, and blood.

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Types of Cerumen

Dry cerumen is grayish-tan; wet cerumen varies in shades of brown.

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External Nose Examination

Assess the external nose for symmetry, shape, discharges, and perforation.

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Signs of Infection

Discharge and inflammation in the nose may indicate infection or allergy.

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Nares Patency Test

Ensure nasal passage patency by applying pressure on one nares while breathing.

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Sinus Tenderness Assessment

Palpate the maxillary and frontal sinuses for tenderness during examination.

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Mouth Inspection

Examine lips, gums, teeth for color, lesions, swelling, and dental hygiene.

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Dental Caries Check

Inspect teeth for caries (cavities) and overall condition.

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Thorax Assessment

A process to evaluate the chest area for respiratory health and abnormalities.

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Tobacco Use Evaluation

Assessment of a client’s smoking habits, including duration and exposure.

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Pack-Years

A measure of smoking history calculated by the number of packs of cigarettes smoked per day multiplied by the number of years smoked.

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Respiratory Alterations

Changes in breathing or lung function, potentially caused by smoking or pollutants.

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Client Positioning

Placing the client upright during thorax assessment to promote lung expansion.

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Purpose of Physical Assessment

To gather baseline data and confirm nursing history.

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Inspection

Visual examination using sight to assess the client.

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Palpation

Examination using the sense of touch to assess body structures.

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Percussion

Tapping the body to evaluate size and consistency of organs.

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Auscultation

Listening to internal body sounds using a stethoscope.

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Equipment for Physical Assessment

Tools like stethoscope, thermometer, and sphygmomanometer for examination.

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Hand Washing

Essential step to reduce microorganism transmission before assessment.

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General Survey

Observation of appearance, hygiene, and grooming during assessment.

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Discoloration of enamel

Staining that changes the color of the tooth enamel.

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Uvula inspection

Examining the uvula for color, size, and symmetry.

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Throat inflammation

Swelling in the throat due to irritation or infection.

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Inspecting tonsils

Checking for size, color, and presence of lesions on the tonsils.

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Neck symmetry assessment

Evaluating both sides of the neck for even appearance and any abnormalities.

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Palpation of thyroid gland

Feeling the thyroid gland to check for enlargement or nodules.

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Swallowing assessment

Observing the movement of the thyroid during swallowing to check function.

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Oropharynx inspection

Visual check of the mouth and throat for lesions or abnormalities.

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Study Notes

Physical Assessment Purposes

  • Obtain baseline data on client's functional abilities.
  • Confirm or refute data from nursing history.
  • Establish nursing diagnoses and care plans.
  • Evaluate the progress of a client's health problem.

Examination Methods

  • Inspection: Visual examination using sight.
  • Palpation: Examination using touch.
  • Percussion: Tapping the body to assess size, borders, and consistency of organs and detect fluids.
  • Auscultation: Listening to sounds within the body.

Examination Equipment

  • Wristwatch (with second hand)
  • Thermometer
  • Sphygmomanometer
  • Stethoscope
  • Otoscope
  • Snellen chart
  • Penlight
  • Safety pin
  • Percussion hammer
  • Tape measure
  • Tongue depressor
  • Gloves
  • Cotton applicator
  • Ruler (millimeter/centimeter)
  • Gauze square
  • Pencil
  • Wisps of cotton
  • Test tubes (hot and cold water, optional)

Examination Procedure

  • Wash hands to reduce microorganism transmission.
  • Gather necessary materials.
  • Create a suitable environment (control drafts, temperature).
  • Explain the procedure to the client and promote cooperation.
  • Allow time for bowel/bladder emptying.

General Survey

  • Note physical appearance (hygiene, grooming, clothing).
  • Assess for clues like make-up type, mood.
  • Examine potential indicators of culture, lifestyle, economic status, and personal preferences.

Posture, Position & Gait

  • Note posture, position, and gait.
  • Evaluate possible musculoskeletal problems, mood, or if pain is present.

Skin Assessment

  • Assess skin color and lesions.
  • Observe skin changes related to possible conditions.

Hair Assessment

  • Note hair color, distribution, quantity, thickness, texture, and lubrication.
  • Look for changes related to possible conditions.

Nail Assessment

  • Assess nail changes for possible underlying issues.
  • Note possible changes related to diet, habits, or conditions.

Client Behaviour

  • Note facial expression, behaviours that might indicate physical abnormalities.
  • Assess behaviours for possible indications.

Level Of Consciousness

  • Assess the client's level of consciousness.
  • Note impact on their ability to cooperate.
  • Look for potential indications.

Vital Signs

  • Assess height, weight, temperature, pulse, respiration, and blood pressure.
  • Monitor how vital signs relate to oxygen levels.

Pain Assessment

  • Assess the client for pain.
  • Examine nonverbal expressions.

Head Assessment

  • Inspect the size, shape, and any deformities, lesions, swelling, or masses of the head.
  • Assess hair condition.

Eye Assessment

  • Check eye position, color, discharges, and any signs of swelling.
  • Assess pupil size, shape, and reaction to light.

Ear Assessment

  • Look for signs of issues with the ears.
  • Assess and observe indications for the presence of hearing problems.

Mouth, Lip, Tongue & Throat Assessment

  • Inspect the colour, texture, hydration, and lesions of the lips.
  • Assess the gums, teeth, and throat for issues such as infection, bleeding, or lesions.
  • Observe uvula color and size.
  • Look for inflammation, lesions, edema, and exudates in the mouth and throat.

Throat Assessment

  • Inspect the throat for inflammation, lesions, edema, and any exudates.
  • Assess the tonsils for color, discharge, and size.

Neck Assessment

  • Look at the neck for symmetry and issues.
  • Assess the thyroid gland for abnormalities.

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