Physical assessment is an important step in the nursing process it is considered the foundation of the nursing process. With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans, therefore, creating wrong interventions and evaluation. Take the quiz below to see how much you know about basic physical assessment.
Place a tongue blade on the front of the tongue and ask the client to say "ah."
Place a tongue blade lightly on the posterior aspect of the pharynx.
Place a tongue blade on the middle of the tongue and ask the client to cough.
Place a tongue blade on the uvula.
A rub occurs only during expiration and produces a light, popping, musical noise.
A rub occurs only during inspiration and the nurse may hear it anywhere.
A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.
A rub occurs only during inspiration and clears with coughing.
Have the client lie down while she takes his blood pressure.
Inflate the cuff to at least 200 mm Hg.
Take blood pressure readings in both of the client's arms.
Inflate the cuff at least another 30 mm Hg after she can't palpate the radial pulse.
A soft, smooth bladder
A hard, rough bladder
A nonpalpable bladder
A palpable bladder located 3″ to 5″ (7.5 to 12.7 cm) above the symphysis pubis
Pale, warm, dry skin
Heart rate of 110 beats/minute
Urine output of 30 ml/hour
Formulates nursing diagnoses
Develops a care plan
Writes client outcomes
To identify genetic and familial health problems
To identify previously undetected diseases and disorders
To identify the client's reason for seeking care
To identify the client's chronic health problems
Have the client stand with feet together and arms at his sides and try to balance. Have the client first do this with his eyes open and then with his eyes closed.
Instruct the client to walk across the room on his heels and to return walking on his toes.
Ask the client to touch the thumb of one hand to each finger on that hand and then do the same thing using the other hand.
Instruct the client to lie on his back and slowly slide his heel down the shin of the opposite leg, from the knee to the ankle.
Providing the adolescent with information about the procedure implies informed consent.
The nurse should inform the adolescent that he may sign a consent form for the surgical procedure if a parent cosigns the form.
The nurse should inform the adolescent that, in most states, only parents may give consent for a minor's medical care.
The nurse may provide the adolescent's legal guardian with information regarding the procedure.
Coma or seizures.
Sunken eyeballs and poor skin turgor.
Increased heart rate with hypotension.
Thirst or irritability.
When did the rash start?
Are you allergic to any medications, foods, or pollen?
How old are you?
What have you been using to treat the rash?
Have you recently traveled outside the country?
Do you smoke cigarettes or drink alcohol?
The bell detects high-pitched sounds best.
The diaphragm detects high-pitched sounds best.
The bell detects thrills best.
The diaphragm detects low-pitched sounds best.
Speaking in a loud voice.
Addressing the client by his first name.
Allowing extra time for the assessment.
Assess the client's level of pain and administer prescribed analgesics.
Assess the client's level of anxiety and provide emotional support.
Prepare the client for pulmonary artery catheterization.
Ensure that the client's family is kept informed of his status.
Pallor and coolness of the left foot.
A decrease in the left pedal pulse.
Loss of hair on the lower portion of the left leg.
Left calf circumference 1" (2.5 cm) larger than the right.
Barely visible outside the tonsillar pillar.
Midway between the tonsillar pillar and the uvula.
Touching the uvula.
Touching each other.
Here's an interesting quiz for you.