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

    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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    Related Documents

    Physical Assessment PDF

    Description

    This quiz covers essential physical assessment methods used in nursing, including various examination techniques such as inspection and auscultation. It also highlights necessary equipment and procedures for effective client evaluation. Understand the importance of these assessments for establishing nursing diagnoses and creating care plans.

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