Physical Assessment Techniques in Nursing

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What is the term for pupils of different sizes?

Dysphasia

Ptosis

Anisocoria (correct)

Consensual reflex

Which term refers to the drooping of the eyelids?

Ptosis (correct)

Aphasia

Anisocoria

Accommodation response

What does PERLA stand for in the context of eye assessment?

The person knows what he or she wants to say, but cannot say it

The person has difficulty coordinating and organizing words into sentences

Pupils equal and reactive to light and accommodation (correct)

Stimulation of one pupil with light, causing both pupils to constrict rapidly, simultaneously, and equally

What is the term for the stimulation of one pupil with light, causing both pupils to constrict rapidly, simultaneously, and equally?

Consensual reflex Signup and view all the answers

Which term is used when focusing on a distant object, causing both pupils to dilate to allow in more light?

Accommodation response Signup and view all the answers

What does dysphasia refer to?

Difficulty coordinating and organizing words into sentences Signup and view all the answers

What is included in the head-to-toe sequence for nursing assessment?

Pupils, neck vein distention, and apical-radial pulse strength Signup and view all the answers

What is the purpose of assessing the chest during the head-to-toe sequence?

To assess heart sounds and breath sounds Signup and view all the answers

What should be assessed when examining the arms during the head-to-toe sequence?

Strength of hand grips and IV or saline lock Signup and view all the answers

Why is it important to assess the abdomen during the head-to-toe sequence?

To assess bowel sounds and bladder distention Signup and view all the answers

What is a key aspect of assessing the perineum during the head-to-toe sequence?

Foley and incontinent. Bed dry. Signup and view all the answers

Why should lower extremities be assessed during the head-to-toe sequence?

To assess skin integrity and edema Signup and view all the answers

What is a crucial aspect of assessing the back and buttocks during the head-to-toe sequence?

Skin integrity and incontinent. Bed dry. Signup and view all the answers

Why is it important to address comfort and needs during the head-to-toe sequence?

To reposition comfortably with pillow support if needed Signup and view all the answers

Why are safety features like bed height and call light accessibility highlighted as important?

To prevent potential accidents or falls Signup and view all the answers

What is the significance of reviewing the steps of each of the skills procedures?

To understand why each step is important and what could happen if they are not followed Signup and view all the answers

What could happen if safety guidelines like bed low and wheels locked are not followed?

Potential accidents or falls may occur Signup and view all the answers

Why is it important to understand why the steps of each skills procedure are important?

So that each step can be followed in the correct order to prevent adverse outcomes Signup and view all the answers

Which of the following is a component of a basic neurological examination?

Assessment of level of consciousness Signup and view all the answers

What is a normal respiratory rate?

Between 12 to 20 breaths per minute Signup and view all the answers

Which of the following is an abnormal respiratory pattern characterized by an abnormally deep and rapid rate of breathing?

Tachypnea Signup and view all the answers

What should be reassessed within at least a 4-hour window, or sooner depending on the severity of the finding?

Abnormal assessment findings Signup and view all the answers

Which of the following is a cardiovascular assessment?

Assessment of neck vein distention Signup and view all the answers

What should be assessed as part of gastrointestinal assessments?

Bowel sounds Signup and view all the answers

Which assessment should include assessment of bladder palpation and last voided time?

Urinary assessment Signup and view all the answers

What should be assessed as part of integumentary assessments?

Color and temperature of skin Signup and view all the answers

What is assessed in musculoskeletal assessments?

Movement and range-of-motion of joints and extremities Signup and view all the answers

What should be assessed during respiratory assessments?

Respiratory effort Signup and view all the answers

What is assessed during a basic neurological examination?

Response to simple commands Signup and view all the answers

Which of the following techniques involves tapping with the tips of the fingers over specific body parts to elicit sounds that can help locate and determine the size of structures beneath the surface?

Percussion Signup and view all the answers

Which of the following is an example of a symptom?

Pain in the chest Signup and view all the answers

What is the purpose of auscultation?

To hear heart, breath, and bowel sounds Signup and view all the answers

Which assessment finding indicates acute respiratory distress?

Retractions Signup and view all the answers

What type of data is not directly observable or measurable?

Symptoms Signup and view all the answers

Which system is assessed in an initial head-to-toe shift assessment?

Respiratory Signup and view all the answers

What is detected by olfaction?

$NH_3$ (ammonia) Signup and view all the answers

Which technique involves tapping with the tips of the fingers over specific body parts to detect areas containing air or fluid?

Percussion Signup and view all the answers

What type of data can be obtained from patient history?

Social history Signup and view all the answers

What does auscultation help detect?

Heart sounds Signup and view all the answers

What does percussion help identify?

Whether a structure is solid or hollow Signup and view all the answers

What is the term for continuous, melodious, musical, or whistling breath sounds due to constriction of the airway?

Rhonchi Signup and view all the answers

When should a nurse perform a physical assessment on a patient?

When things do not feel right Signup and view all the answers

What is the term for a rapid rate of breathing?

Tachypnea Signup and view all the answers

What type of assessment is performed when time constraints only allow the nurse to check one system or only the systems related to the patient’s disease process?

Focused assessment Signup and view all the answers

What eye response does the nurse assess by briefly shining a penlight in one eye of a patient and observing both pupils’ response?

Consensual reflex Signup and view all the answers

What is the term for a normal rate and pattern, with equal depth, of respirations?

Eupnea Signup and view all the answers

Which breath sounds are caused by air moving over secretions or alveoli opening up, and can be fine or coarse and do not clear with coughing?

Crackles Signup and view all the answers

What is the purpose of a physical assessment?

All of the above Signup and view all the answers

What is used to assess pupil constriction of the eyes and to examine the oral and nasal mucous membranes?

Penlight Signup and view all the answers

What is used to inspect the lining of the nose, tympanic membranes, and ear canals?

Otoscope Signup and view all the answers

What eye response is assessed by holding a finger in front of the patient’s face and slowly increasing and then decreasing the distance between the finger and the patient’s face while observing for dilation and then constriction of pupils?

Accommodation response Signup and view all the answers

Physical Assessment Techniques in Nursing

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Questions and Answers

What is the term for pupils of different sizes?

Which term refers to the drooping of the eyelids?

What does PERLA stand for in the context of eye assessment?

What is the term for the stimulation of one pupil with light, causing both pupils to constrict rapidly, simultaneously, and equally?

Which term is used when focusing on a distant object, causing both pupils to dilate to allow in more light?

What does dysphasia refer to?

What is included in the head-to-toe sequence for nursing assessment?

What is the purpose of assessing the chest during the head-to-toe sequence?

What should be assessed when examining the arms during the head-to-toe sequence?

Why is it important to assess the abdomen during the head-to-toe sequence?

What is a key aspect of assessing the perineum during the head-to-toe sequence?

Why should lower extremities be assessed during the head-to-toe sequence?

What is a crucial aspect of assessing the back and buttocks during the head-to-toe sequence?

Why is it important to address comfort and needs during the head-to-toe sequence?

Why are safety features like bed height and call light accessibility highlighted as important?

What is the significance of reviewing the steps of each of the skills procedures?

What could happen if safety guidelines like bed low and wheels locked are not followed?

Why is it important to understand why the steps of each skills procedure are important?

Which of the following is a component of a basic neurological examination?

What is a normal respiratory rate?

Which of the following is an abnormal respiratory pattern characterized by an abnormally deep and rapid rate of breathing?

What should be reassessed within at least a 4-hour window, or sooner depending on the severity of the finding?

Which of the following is a cardiovascular assessment?

What should be assessed as part of gastrointestinal assessments?

Which assessment should include assessment of bladder palpation and last voided time?

What should be assessed as part of integumentary assessments?

What is assessed in musculoskeletal assessments?

What should be assessed during respiratory assessments?

What is assessed during a basic neurological examination?

Which of the following techniques involves tapping with the tips of the fingers over specific body parts to elicit sounds that can help locate and determine the size of structures beneath the surface?

Which of the following is an example of a symptom?

What is the purpose of auscultation?

Which assessment finding indicates acute respiratory distress?

What type of data is not directly observable or measurable?

Which system is assessed in an initial head-to-toe shift assessment?

What is detected by olfaction?

Which technique involves tapping with the tips of the fingers over specific body parts to detect areas containing air or fluid?

What type of data can be obtained from patient history?

What does auscultation help detect?

What does percussion help identify?

What is the term for continuous, melodious, musical, or whistling breath sounds due to constriction of the airway?

When should a nurse perform a physical assessment on a patient?

What is the term for a rapid rate of breathing?

What type of assessment is performed when time constraints only allow the nurse to check one system or only the systems related to the patient’s disease process?

What eye response does the nurse assess by briefly shining a penlight in one eye of a patient and observing both pupils’ response?

What is the term for a normal rate and pattern, with equal depth, of respirations?

Which breath sounds are caused by air moving over secretions or alveoli opening up, and can be fine or coarse and do not clear with coughing?

What is the purpose of a physical assessment?

What is used to assess pupil constriction of the eyes and to examine the oral and nasal mucous membranes?

What is used to inspect the lining of the nose, tympanic membranes, and ear canals?

What eye response is assessed by holding a finger in front of the patient’s face and slowly increasing and then decreasing the distance between the finger and the patient’s face while observing for dilation and then constriction of pupils?

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