PHYSICAL ASSESSMENT, Part II, 50

1. In the interview portion of the physical assessment, since we are not actually touching the patient, there is no need to wash our hands.

True

False

page 107, Always wash your hands before beginning the physical assessment. The interview portion is only a portion of the physical assessment. After or during the interview, the rest of the physical assessment process will require contact.

Explanation

page 107, Always wash your hands before beginning the physical assessment. The interview portion is only a portion of the physical assessment. After or during the interview, the rest of the physical assessment process will require contact.

2. Where is S1 auscultated most clearly?

Apex of the heart

Base of heart

Around the heart

All over the heart

page 113

Explanation

page 113

3. A patient has just been admitted. During physical assessment, it was observed that patient had decreased skin turgor and dried outer lips. What would be the most appropriate thing to offer this patient while the physical assessment is going on?

A chair to sit on

Medication

Water

Some snacks

pate 109. The patient is showing signs of dehydration as manifested by decreased skin turgor.

Explanation

pate 109. The patient is showing signs of dehydration as manifested by decreased skin turgor.

4. Lateral spinal curvature

Spina Bifida

Kyphosis

Lordosis

Scoliosis

page 113

Explanation

page 113

5. Teaching patients to perform breast self-exams is only directly related to females

True

False

page 111 - Breast self-exams is related to both males and females

Explanation

page 111 - Breast self-exams is related to both males and females

6. When performing a head-to-toe assessment, we normally begin with a neurologic assessment . What is the next?

Skin, hair, head and neck including eyes, ear, nose and mouth

Chest, back, arm, abdomen

Perineal area, legs and feet

Eyes and ears alone

page 107

Explanation

page 107

7. A patient with increased turgor in his lower extremities manifested by smooth, taut, shiny skin that cannot be grasped or raised is most likely to have:

Enema

Decubitus

Edema

Infection

page 109

Explanation

page 109

8. The consumption of alcohol, tobacco, caffeine, or herbal products are important in health history and which are part of what?

Illegal activity

Habits and lifestyle patterns

Fun and pleasure

Rest and recreation

page 104

Explanation

page 104

9. Standardized objective measurement of the level of consiousness

Glasgow Coma Scale

PERRLA

Rhomberg Test

Motor function assessment

page 109

Explanation

page 109

10. In person with good cardiac function and distal perfusion, how long should a capillary refill take place?

Less than 3 seconds

More than 3 seconds

More than 5 seconds

Around 5 seconds

page 115

Explanation

page 115

11. Match the review of organ systems on the left with information that we need to assess on the right

Reproduction

Respiratory

Cardiac

Hematologic

Lymph nodes

page 103, Box 5-7

Explanation

page 103, Box 5-7

Submit

12. We know that the nurse knows the right time to do a physical assessment when she says:

"I will do it as soon as possible"

"I think the next shift will have to do it"

"After I give the medication"

"Maybe later, when I am done with others"

page 106

Explanation

page 106

13. When doing a respiratory assessment to a patient, which of the following is the most appropriate technique?

Use a stethoscope over the clothing of a patient who feels cold

Instruct patient to breathe through his or her mouth quietly and more deeply and slowly than in a usual respiration

Allow a patient with a slight lower back pain to lie supine on bed

Listen to the heart sound at the same time that your are listening to the lung sounds

page 111

Explanation

page 111

14. Match the review of organ systems on the left with information that we need to assess on the right.

Gastrointestinal

Genitourinary

Neurologic

Psychiatric

page 103, Box 5-7

Explanation

page 103, Box 5-7

Submit

15. The nurse tells a 75 year old patient that she will have to do a "head to toe" assessment on him. The patient asks, "what is that"? Her best answer would be ...

I will need to determine the etiology of any pathologic symptoms you might have.

Oh nothing, it is just something that we do.

It is a way for us to know how we are going to take care of you later

Maybe you can tell me how you got here.

page 106 - Older Adults - Why do you think this is the right answer? Simplicity, clarity and directness of response.

Explanation

page 106 - Older Adults - Why do you think this is the right answer? Simplicity, clarity and directness of response.

16. Indicative of acute or chronic respiratory distress

Height

Posture

Weight

Hair loss

page 110

Explanation

page 110

17. An abnormal cycle of respiration that begin with slow, shallow respiration that become rapid, then become slower and are followed by periods of apnea (20 seconds). Normally caused by hear failure, opioid overdose, renal failure, meningitis, and severe head ache.

Kussmaul

Cheyne-stokes

Botte's

Whooping sneeze

page 110

Explanation

page 110

18. When auscultating for lung sounds, which part of the stethoscope is designed to transmit the higher pitch of abnormal sounds

Ear piece

Bell

Diaphragm

Tubes

page 111

Explanation

page 111

19. Which of the following are true regarding cultural sensitivity

All members of one cultural group behave in exactly the same manner

As a nurse, it is important to identify and examine our own cultural and ethnic beliefs

Cultural and ethnic diversity have no impact in health care

Patient's response to signs and symptoms are independent of their cultural values

page 104

Explanation

page 104

20. PERRLA refers to

Motor function

Order of assessment

Level of consciousness

Pupillary response

page 109

Explanation

page 109

21. Before the beginning of a physical examination, to make the patient more comfortable, what should be done first

Give patient a warm blanket

Ask if patient wants a glass of water

Offer patient to empty his/her bladder

Provide a small

page 107

Explanation

page 107

22. Match the pitting edema scale with the traits on the right:

1+

2+

3+

4+

page 117, Box 5-11

Explanation

page 117, Box 5-11

Submit

23. A swayback, an increased lumbar curvature

Spina Bifida

Kyphosis

Lordosis

Scoliosis

page 113

Explanation

page 113

24. Which of the following is not a peripheral pulse?

Ulnar

Femoral

Brachial

Humoral

page 114

Explanation

page 114

25. Two significant alterations in bowel sounds:

Decreased and increased bowel sounds

Loud and quiet bowel sounds

Fetid and scentless bowel sounds

Noisy and loud bowel sounds

page 116

Explanation

page 116

26. Match the review of organ systems on the left with information that we need to assess on the right.

General Constitution Symptoms

Skin

Skeletal

Head

Endocrine

page 103, Box 5-7

Explanation

page 103, Box 5-7

Submit

27. Abnormal swishing sounds heard over organs, glands and arteries and results from an abnormality in an artery resulting from narrow or partially occluded artery such as those in atherosclerosis

Thrill

Crackles

Bruits

Wheezes

page 110

Explanation

page 110

28. A vibrating sensation perceived when an artery is palpated and is not expected when examining a carotid pulse.

Bruit

Thrill

Crackles

Rhonci

page 110

Explanation

page 110

29. Rubbing, grating or squeaky sound upon auscultation; as if two pieces of leather are being rubbed together

Pulmonary friction

Pleural friction rub

Pulmonary bruising

Whooping cough

page 112

Explanation

page 112

30. Exaggeration of the posterior curvature of the thoracic spine

Spina Bifida

Kyphosis

Lordosis

Scoliosis

page 113

Explanation

page 113

31. Match the levels of consciousness on the left with the behaviors on the right

Syncope

Fugue

Amnesia

Submit

32. Vital signs are reliable even when there is a central nervous system deficit.

True

False

Pulse and Blood pressure are not reliable indicators of central nervous system deficits. page 109

Explanation

Pulse and Blood pressure are not reliable indicators of central nervous system deficits. page 109

33. The difference between a "head to toe" assessment and a "focused assessment"

Head to toe is systemic while focused concentrates on regional parts

Head to toe is completed when the patient is admitted; focused concentrates on a particular part of a body

Head to toe is done on every shift while focused is done when the person is admitted

Both RN's and LPN's should do head to toe assessments as well as focused assessments

page 106 When to perform a Nursing Physical Assessment

Explanation

page 106 When to perform a Nursing Physical Assessment

34. The first normal heart sound S1 occurs when?

Closure of the AV valves and signals the start of systole

Closure of the AV valves and signals the end of systole

Opening of the AV valves and signals the start of systole

Opening of the AV valves and signlas the end of systole

page 113

Explanation

page 113

35. This happens when there is a decreased supply of oxygenated blood to the tissues often caused by a narrowing of an artery

Ischemia

Claudication

Hypoventilation

Atelactesis

page 114

Explanation

page 114

36. Cramp-like pain in the lower extremities usually after walking

Ischemia

Claudication

Hypoventilation

Atelactesis

page 114

Explanation

page 114

37. When auscultating for lung sounds, place the stethoscope firmly and tightly on the skin, and listen for one full inspiratory-expiratory cycle at each point.

True

False

firmly, but not tightly ...page 111

Explanation

firmly, but not tightly ...page 111

38. Heard in patients with coronary artery disease after MI (myocardial infarction), heard late in diastole when the atria contracts.

S1

S2

S3

S4

page 113

Explanation

page 113

39. Which of the following is not a symptom?

Soreness

Pruritus

Flatus

Pain

page 115

Explanation

page 115

40. In the mnemonic used for assessments, what does PS stand for in ABC in and out, PS?

Painful sensation

Problem and solution

Pain and safety

Pernicious stimulation

page 108

Explanation

page 108

41. Lubb-dubb is caused by

Closure of the atrioventricular and semilunar valves respectively

Closure of the semilunar and atrioventricular valves respectively

Closure of the atrioventricular and semilunar valves simultaneously

Closure of the atrioventricular valve and opening of the semilunar valve respectively

page 113

Explanation

page 113

42. A person who is just being admitted complains of pain on his right foot. What is the proper way to provide this patient a proper physical assessment?

Do a focused assessment on the foot first and do the complete physical assessment later

If a complete physical assessment is necessary, it is best to assess any painful areas last.

Focus on the pain and provide comfort before anything else.

Since the patient is a new admit, concentrate on the general physical assesment only

page 106, Methods of performing a nursing physical assessment

Explanation

page 106, Methods of performing a nursing physical assessment

43. When does normal heart sound S2 occur?

With the closure of the AV valve and signals the end of systole

With the opening of the AV valve and signals opening of systole

With the opening of the semilunar valves and signals the beginning of systole.

With the closure of the semilunar valves and signals the end of systole

page 113

Explanation

page 113

44. A neurologic examination pertaining to the sensations of body movements and awareness of posture and cerebellar function

Deep tendon reflexes

Proprioception

Cranial nerve assessment

Pupillary reflex

page 109

Explanation

page 109

45. Which of the following are included in the neurologic assessment?

Motor function

Range of motion

Level of consiousness

Pupillary response

page 107-109

Explanation

page 107-109

Submit

46. What do the signs and symptoms of Cushing's triad include? They are typical of someone who had traumatic brain injury

Increase in systolic blood pressure

Bradycardia

Irregular breathing pattern

Widening pulse pressure

page 109

Explanation

page 109

Submit

47. Match the adventitious breath sounds on the left with their traits on the right

Crackles

Wheezes

Stridor

Rhonci

page 113

Explanation

page 113

Submit

48. Match the level of consciousness on the left with the behavior on the right

Consciousness

Confusion

Lethargy (hypersomnia)

Delirium

Coma

Submit

49. Coma has 4 stages and death as the final phase. Match the terms on the left with the definitions on the right

Stage I (stupor)

Stage II (light coma)

Stage III (deep coma)

Stage IV

Brain Death

Submit

Physical Assessment, Part II, 50

1. In the interview portion of the physical assessment, since we are not actually touching the patient, there is no need to wash our hands.

2.

What first name or nickname would you like us to use?

2. Where is S1 auscultated most clearly?

3. A patient has just been admitted. During physical assessment, it was observed that patient had decreased skin turgor and dried outer lips. What would be the most appropriate thing to offer this patient while the physical assessment is going on?

4. Lateral spinal curvature

5. Teaching patients to perform breast self-exams is only directly related to females

6. When performing a head-to-toe assessment, we normally begin with a neurologic assessment . What is the next?

7. A patient with increased turgor in his lower extremities manifested by smooth, taut, shiny skin that cannot be grasped or raised is most likely to have:

8. The consumption of alcohol, tobacco, caffeine, or herbal products are important in health history and which are part of what?

9. Standardized objective measurement of the level of consiousness

10. In person with good cardiac function and distal perfusion, how long should a capillary refill take place?

11. Match the review of organ systems on the left with information that we need to assess on the right

12. We know that the nurse knows the right time to do a physical assessment when she says:

13. When doing a respiratory assessment to a patient, which of the following is the most appropriate technique?

14. Match the review of organ systems on the left with information that we need to assess on the right.

15. The nurse tells a 75 year old patient that she will have to do a "head to toe" assessment on him. The patient asks, "what is that"? Her best answer would be ...

16. Indicative of acute or chronic respiratory distress

17. An abnormal cycle of respiration that begin with slow, shallow respiration that become rapid, then become slower and are followed by periods of apnea (20 seconds). Normally caused by hear failure, opioid overdose, renal failure, meningitis, and severe head ache.

18. When auscultating for lung sounds, which part of the stethoscope is designed to transmit the higher pitch of abnormal sounds

19. Which of the following are true regarding cultural sensitivity

20. PERRLA refers to

21. Before the beginning of a physical examination, to make the patient more comfortable, what should be done first

22. Match the pitting edema scale with the traits on the right:

23. A swayback, an increased lumbar curvature

24. Which of the following is not a peripheral pulse?

25. Two significant alterations in bowel sounds:

26. Match the review of organ systems on the left with information that we need to assess on the right.

27. Abnormal swishing sounds heard over organs, glands and arteries and results from an abnormality in an artery resulting from narrow or partially occluded artery such as those in atherosclerosis

28. A vibrating sensation perceived when an artery is palpated and is not expected when examining a carotid pulse.

29. Rubbing, grating or squeaky sound upon auscultation; as if two pieces of leather are being rubbed together

30. Exaggeration of the posterior curvature of the thoracic spine

31. Match the levels of consciousness on the left with the behaviors on the right

32. Vital signs are reliable even when there is a central nervous system deficit.

33. The difference between a "head to toe" assessment and a "focused assessment"

34. The first normal heart sound S1 occurs when?

35. This happens when there is a decreased supply of oxygenated blood to the tissues often caused by a narrowing of an artery

36. Cramp-like pain in the lower extremities usually after walking

37. When auscultating for lung sounds, place the stethoscope firmly and tightly on the skin, and listen for one full inspiratory-expiratory cycle at each point.

38. Heard in patients with coronary artery disease after MI (myocardial infarction), heard late in diastole when the atria contracts.

39. Which of the following is not a symptom?

40. In the mnemonic used for assessments, what does PS stand for in ABC in and out, PS?

41. Lubb-dubb is caused by

42. A person who is just being admitted complains of pain on his right foot. What is the proper way to provide this patient a proper physical assessment?

43. When does normal heart sound S2 occur?

44. A neurologic examination pertaining to the sensations of body movements and awareness of posture and cerebellar function

45. Which of the following are included in the neurologic assessment?

46. What do the signs and symptoms of Cushing's triad include? They are typical of someone who had traumatic brain injury

47. Match the adventitious breath sounds on the left with their traits on the right

48. Match the level of consciousness on the left with the behavior on the right

49. Coma has 4 stages and death as the final phase. Match the terms on the left with the definitions on the right

50. Where is S2 auscultated more clearly?