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Terms in this set (116)
Which scale is used to weight infants?
Platform
Which behavioral finding would alert the nurse to possible older-adult abuse?
Physical and/or cognitive impairment
While assessing a victim of intimate partner violence, which common physical indicator with the nurse anticipate?
Overmedicated
Undermedicated
Human bite marks
Pain while urinating
Human bite marks
Which physical assessment technique involves the use of a stethoscope?
Auscultation
Which patient position promotes relaxation of abdominal muscles during a physical examination?
Dorsal Recumbent
Which action made by a nurse during psychological preparation of a patient before physical examination can limit the patient's communication ability?
Exhibiting a quiet, formal behavior
Which position is preferred for performing a rectal examination on a patient?
Sims'
Which action during palpation made by the new nurse would require correction by the charge nurse?
Palpates tender areas first
Encourages the patient to take slow, deep breath's
Ask a patient to point to more sensitive areas
Warms hands before touching patient
Palpates tender areas first
Which information would the nurse include in a teaching session to new orienting nurses about keeping a physical examination well organized?
Carry out painful procedures of the end of the examination
Which criterion is being measured by the nurse is the Palmer surface of his or her fingers (Finger pads) to palpate the skin?
Tenderness
Statement made by the nurse indicating a correct understanding of physical examination positioning?
" while assessing a patient's heart, I'll ask the patient to assume the lateral recumbent position "
The nurse would further assess for which condition when a patient's breath has a sweet and fruity odor?
Diabetic acidosis
When the patient's urine smells of ammonia, which condition with the nurse assess for?
Renal failure and urinary tract infection
Which information with the nurse she was a young mother to help her quickly evaluate whether her child has a fever?
Place the back of the hand against the child's forehead
Which scale would be used to weigh in obese patient who had extensive surgery and is nonweightbearing for 24 hours?
Bed and chair
Which behavioral finding in children indicates possible abuse?
Regressed behavior
Which technique indicates the nurse has a correct understanding of using palpation to examine different areas of the body?
Use the Palmer surface of the hand to assess excursion of the thorax
Use the pads of the fingertips to examine any swelling in the thyroid gland
Use the entire Palmer surface of the hand to examine the size, shape, and tenderness of the liver.
Which position is usually recommended when the nurse is assessing a patient's heart and lungs?
Sitting and dorsal recumbent
Which factor causes body odor?
Poor hygiene and hyperhidrosis and bromhidrosis
Which factor affects a patient's ability to assume various positions during a physical examination?
Mobility, physical strength, ease of breathing
Which position would the nurse instruct the patient with a cough to assume for a proper physical examination?
Sitting
Which physical examination technique is used to measure length swelling?
Palpation using the pads of the fingers
Which statement indicates a correct understanding of the difference between percussion and palpitation?
"Percussion is the use of only the fingers to vibrate the underlying tissues and organs, where as palpation involves the use of different parts of the hand to assess body parts."
Which area of the hand with the nurse use in palpating the liver?
Entire Palmar surface of the hand and Palmar surface of the fingers
Which question with the nurse ask a patient according to the cage questionnaire to assess alcohol abuse?
" do you feel guilty about drinking?"
" are you annoyed by those who criticize your drinking?"
"Have you ever tried cutting down on your drinking?"
Which action with the nurse take while examining a child?
Ask a child's parents open ended questions
Which parameter can be measured by lightly grasping the body part with the fingertips?
Turgor and elasticity
Which physical examination technique is required when assessing a patient?
Palpitation and percussion and auscultation
Which cancer screening is recommended for a 30-year-old female patient?
Uterine and ovarian and endometrial
At what angle with the nurse elevate the head of the examination table so that the patient is comfortable during the physical assessment?
30°
Which interpretation would the nurse make after observing a patient skin that lifts easily and falls immediately back to its resting position?
This indicates a normal skin finding
Which body part is the best site for the nurse to inspect for jaundice?
Sclera
Which technique with the nurse used to assess the elasticity of the patient skin?
I grasping the skin of the forearm with the fingertips and releasing it
Pallor of the face, conjunctiva, nail beds, and palms of the hands is a finding that would alert the nurse to which condition in a patient?
Anemia
Which assessment finding is a clinical indicator of abuse in an older adult?
Bedsores, Excoriation on wrist or legs, hematomas at various healing stages
Characteristics of the hair are associated with diabetes and thyroid -itis?
Thinning and alopecia
Which characteristic of the skin is measured using the dorsum of the hand?
Temperature
Which skin discoloration would alert the nurse to hypoxia?
Bluish
Which information will the nurse use to guide the examination of a patient's integumentary system?
History of allergies, history of trauma to the skin, past medical history, medications used at home
Which lesion is an example of nodule?
Wart
Which lesion is the result of a mosquito bite?
Wheal
A wheal is a irregularly shaped, superficial localized edema that varies in size and is caused by a hive or a mosquito bite.
Which condition will cause a patient's nails to have a large angle and a softening of the nailbed?
Chronic deoxygenation problem
Which term describes a circumscribed elevated solid mass that is deep and firm with a diameter of 1 to 2 cm?
Nodule
Which technique is the nurse performing when using the sense of touch with the service of the hand to collect clinical data about a patient skin?
Palpation
Which term is used for an abnormal drooping of the lid over the pupil?
Ptosis
Which statement regarding the lacrimal apparatus is true?
The nasal lacrimal duct sometimes blocks the flow of tears
Which finding indicates strabismus in a patient?
Inability to focus both eyes on an object simultaneously
Which eye abnormality would be caused by a neuromuscular injury?
Crossed
Which I finding would alert the nurse that the patient is experiencing hyperthyroidism?
Bulging
Which function is the responsibility of the immune system and lymph nodes?
Protect the body from foreign antigens
Remove damage cells from circulation
Provide a partial barrier to malignant cell growth
Which color of the lips indicates carbon monoxide poisoning?
Bright red
Which color is a normal tympanic membrane?
Gray
What early discolorations of teeth would alert the nurse that the patient may be developing caries?
Chalky white
Which Determination would the nurse most likely be trying to make by asking a patient if there has been trauma to the nose?
Causes of septal deviation and asymmetry of the external nose
Which component of the air is located in the external region?
Mastoid
Which parents statement indicates successful teaching regarding care for a child who has frequent nosebleeds?
I should make my child sit up and lean forward when a nose bleed occurs
Which assessment technique will the nurse use when examining a patient's head and neck?
Palpation and inspection
Which rationale explains the reason a nurse would ask a patient about snoring at night?
To identify septal deviation
Which area of the nose with the nurse assessed to determine evidence of a nosebleed?
Mucosa
Which assessment finding would the nurse observe in a patient who is nystagmus?
Involuntary and rhythmical oscillations of the eyes
At which distance in centimeters with the nurse directed patient to sit or stand during the assessment of extraocular movements?
60cm
Which statement regarding the neck assessment is accurate?
Visual inspection and palpitation are included in the exam
Technique with the nurse use to assess the patient's thyroid gland?
Inspect the neck for the presence of obvious masses
Which alteration causes the patient to be unable to focus eyes on an object simultaneously, making the eyes looked crossed?
Impairment of extraocular muscles
Which sound is considered an adventitious (abnormal) breath sound?
Rhonchi, crackles, wheezes
Which type of breath sound is usually created by the air moving to the larger airways in a healthy individual?
Bronchovesicular
Which statement is true about a pleural friction rub?
Dry or grating sounds are characteristics of pleural friction rub
Which breath sounds heard only over the trachea and a healthy individual?
Bronchial
If the nurse suspects mucus accumulation in the lungs, which part of the lungs should be given attention when performing a physical exam?
Lower lobes
Which sounds are considered normal breath sounds?
Bronchial
Which sounds are heard over the right and left lung bases?
Crackles
Which sounds are only heard during inspiration?
Crackles
Which common imaginary line is observed in anterior and lateral chest landmarks?
Anterior auxiliary line
Vesicular breath sounds
Vesicular breath sounds are created by air moving through small airways
When examining a patient from behind, which anatomic chest wall imaginary line extends down from the center of the neck?
Midsternal
The nurse palpated the tactile fremitus and detected abnormalities. The nurse suspects Accumulation of fluid in the lungs. Which tone in the patient would confirm the suspicion?
Normal tone
Which characteristic of adventitious sounds heard louder during expiration?
Hi - pitch, continuous musical sounds
For which reason with the nurse instruct the student nurse to avoid deep palpation during physical assessment?
Rib fractures
Which type of muscles do women commonly used to breathe?
Costal
Which Adventitious sounds are heard if there is an inflammation of the plural membrane?
Pleural friction rub
Which finding difference between an anterior and posterior thorax assessment?
Heart and breasts
Anterior findings differ from posterior findings because of the presence of heart and female breast tissue in the anterior region. The ribs, sternum, and vertebral column may not be a reason for a difference between anterior and posterior findings.
Which sounds most commonly auscultated at the basis of the lungs during inspiration?
Crackles
Which sounds are heard loudest over the anterolateral surface of the lung?
Pleural friction rub
Which location are low pitch sounds heard?
Trachea and bronchi
Which position is appropriate to assess the posterior thorax?
Sitting
Which type of normal breath sound is observed during a lateral thorax examination?
Vesicular
Which sounds are only heard during inspiration?
Crackles
Which type of breath sound is created by the air moving through the larger airways in a healthy individual?
Bronchovesicular
Which sounds are heard
over the right and left lung bases?
Crackles
Sibilant wheezes
Sonorous wheezes
Pleural friction rub
Crackles
Which imaginary line is observed in the anterior chest landmark?
Midclavicular line
At which location are low pitch (Ronchi) sounds heard?
Trachea and bronchi
Examining a patient from behind, which anatomic chest wall imaginary line extends down the center of the neck?
Vertebral
Which position can be well tolerated by the patient with respiratory difficulties while performing a physical assessment of the anterior thorax and lungs?
Sitting
Characteristics of pleural friction rub
Dry, rubbing or grating sound
Does not clear with coughing
Heard loudest over lower lateral anterior surface
Bronchovesicular
The bronchovesicular sounds are blowing sounds that are medium pitched and of medium intensity
The patient reports having a sore throat, coughing, and sneezing. In a focused assessment, which finding supports the patients reported symptoms related to upper respiratory infection?
Retropharyngeal lymph nodes are enlarged and firm
Tuberculosis statements made by patient
I am addicted to smoking
I am losing weight unintentionally
My grandfather suffered from TB
Which rationale explains why a patient with congenital heart disease develops clubbing?
It is caused by insufficient oxygenation at the periphery
Which pulse is difficult to palpating in a normal patient?
Popliteal pulse
Risk factors for heart disease
Smoking
Lack of Exercise
Alcohol Ingestion
flexible sigmoidoscopy is used to screen for which condition?
Rectal cancer
Which statement regarding the assessment of jugular veins is true?
They should be inspected first to measure the venous pressure
How does the nurse measure a brachial pulse?
Placing the fingertips of the first three fingers in the grove between the biceps
Which statement regarding the brachial pulse is true?
It is located along the medial side of the extended arm
How often should a 52 year old patient receive a colonoscopy?
Every 10 years
Which position is the most suitable for an abdominal examination?
Dorsal Recumbent position
When palpating the patient's pulse, the nurse places the fingertips between the first and second toes and slowly moves up the dorsum of the foot. Which pulse is the nurse palpating?
Dorsalis Pedis pulse
While assessing the abdominal skin of a patient, the nurse observed bruising. Which condition would the nurse suspect?
Past Trauma
Accidental Injury
Bleeding Disorder
In addition to cyanotic lips and nail beds, nasal flaring, and pursed lips, which sign would directly indicate that a patient is suffering from cardiac or pulmonary insufficiency?
Clubbing of the fingers
While assessing the bowel mobility of a patient, the nurse finds an absence of sounds. Which condition might be the reason?
Peritonitis
Paralytic ileus
Which condition causes difficulty swallowing?
Alteration in the Gastrointestinal (GI) system
While auscultating the bowel sounds in a patient, the nurse reports borborygmi. Which characteristic sound is present?
Hyperactive sound
Which change is observed in the breasts during pregnancy?
Breasts reach full size
Nipples become erect
Breast tissue becomes softer
Skin of the breasts appear loose
Nipples become erect
Which condition is assessed by a papanicolaou (PAP) test and biopsy?
Breast
Cancer
Ovarian cancer
Uterine cancer
Endometrial cancer
Endometrial cancer
In which stage of breast maturation does elevation of the nipple occur?
Stage 1
Which part of the female genital system is assessed for lesions and hemorrhoids?
Anus
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