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NURSINGTB.COM Chapter22:Abdomen MULTIPLECHOICE 1.Thenurseispercussingtheseventhrightintercostalspaceatthemidclavicularlineovertheliver.Which soundshouldthenurseexpecttohear? a.Dullness b.Tympany c.Resonance d.Hyperresonance ANS:A Theliverislocatedintherightupperquadrantandwouldelicitadullpercussionnote. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 2.Whichstructureislocatedintheleftlowerquadrantoftheabdomen? a.Liver b.Duodenum c.Gallbladder d.Sigmoidcolon ANS:D Thesigmoidcolonislocatedintheleftlowerquadrantoftheabdomen. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 3.Apatientishavingdifficultyswallowingmedicationsandfood.Thenursewoulddocumentthatthispatient has: a.Aphasia. b.Dysphasia. c.Dysphagia. TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)320 NURSINGTB.COM PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK Physical assessment is an inevitable procedure not just for nurses but also for doctors. Establishing a good assessment would later-on provide a more accurate diagnosis, planning, and better interventions and evaluation, that’s why it’s important to have a good and strong assessment. Below is your ultimate guide in performing a head-to-toe physical assessment. You might want to print a copy and bring it during your hospital duty, making your physical assessment better and more accurate! Skull, Scalp & Hair
Normal Findings: Skull
Scalp
Hair
Face
CN V (Trigeminal)1. Sensory Function
2. Motor function
CN VII (Facial)1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
2. Motor function
Normal Findings
Eyebrows, Eyes, and Eyelashes
Normal findings Eyebrows
Eyes
Eyelashes
Eyelids and Lacrimal Apparatus
Normal Findings Eyelids
Lacrimal Apparatus
Conjunctivae
In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as follow:
Normal Findings
Sclerae
Normal Findings
Cornea
Normal findings
Anterior Chamber and Iris
Normal Findings
Pupils
Normal Findings
Cranial Nerve II (optic nerve)
Peripheral vision or visual fields
Follow the steps on conducting the test:
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
Follow the given steps:
Ears
Normal Findings
Nose and Paranasal Sinuses
Paranasal Sinuses
Normal Findings
Cranial Nerve I (Olfactory Nerve)
Mouth and Oropharynx LipsInspected for:
Normal Findings:
Temporomandibular
Normal Findings:
GumsInspected for:
Normal Findings:
TeethInspected for:
Normal Findings
TonguePalpated for:
Normal Findings:
UvulaInspected for:
Normal Findings:
TonsilsInspected for:
Neck
Normal Findings:
Normal Findings:
Normal Findings:
Anterior approach:
Normal Findings:
Thorax (Cardiovascular System)Inspection of the Heart
Normal Findings:
Palpation of the Heart
Normal Findings:
Percussion of the Heart
Auscultation of the Heart
Positioning the client for auscultation:
Auscultating the heart:
Normal Findings:
Breast
|
Functional level | Lovett Scale | Grade | Percentage of normal |
No evidence of contractility | Zero (Z) | 0 | 0 |
Evidence of slight contractility | Trace (T) | 1 | 10 |
Complete ROM without gravity | Poor (P) | 2 | 25 |
Complete ROM with gravity | Fair (F) | 3 | 50 |
Complete range of motion against gravity with some resistance | Good (G) | 4 | 75 |
Complete range of motion against gravity with full resistance | Normal (N) | 5 | 100 |
Normal Findings
- Both extremities are equal in size.
- Have the same contour with prominences of joints.
- No involuntary movements.
- No edema
- Color is even.
- Temperature is warm and even.
- Has equal contraction and even.
- Can perform complete range of motion.
- No crepitus must be noted on joints.
- Can counteract gravity and resistance on ROM.
See Also
- Complete Head-to-Toe Physical Assessment Cheat Sheet
- Ultimate Guide to Head-to-Toe Physical Assessment
- Head-to-Toe Physical Assessment [VIDEOS]