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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 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 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?" 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 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 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 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 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 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 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 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? Nipples become erect Which condition is assessed by a papanicolaou (PAP) test and biopsy? 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 Sets with similar termsNCLEX Questions - Fundamentals #141 terms josenberg Health Assesment FInal (HESI)114 terms jgarc144 Sets found in the same folderCh 18-20127 terms mfamilia VITAL SIGNS52 terms Mikaylalala123 Essentials to Nursing Exam- Nursing Skills Related…51 terms pauline_seremetis ch 12: preschooler through adolescence43 terms cassidymcalpine Other sets by this creatorHEART FLOWS/ABDOMINAL EXAM/CRANIAL NERVES25 terms Mikaylalala123 HYGIENE12 terms Mikaylalala123 DOCUMENTATION19 terms Mikaylalala123 MCB2010L Week 211 terms Mikaylalala123 Other Quizlet setsDAT Chemistry470 terms haleydebnam Early Intervention Child Mental Health13 terms clare_schoch9 Chapter 7 Human Growth and Development27 terms Adria_Edwards3 Waxing D45 terms tmyho Related questionsQUESTION What are common characteristics of people with neuroses? 8 answers QUESTION what is the purpose of dental indices? 15 answers QUESTION Two principal types of connective tissue in a muscle are 15 answers QUESTION How long does alcohol stay in your system? 15 answers What should the nurse do before conducting a physical examination of a patient?Prior to conducting a physical examination of a patient, the nurse should obtain and check needed equipment, identify how to maintain patient privacy during the examination, and wash hands before beginning the examination.
What is the first action during physical assessment?Palpation - is the first step of the assessment, where we will touch the patient. Many breathing difficulties can be seen during this step. Some systemic problems can be detected during this part of the exam as well as just mechanical breathing problems.
Which factor affects a patients ability to assume various positions during a physical examination?Patients' abilities to assume positions depend on their physical strength, mobility, ease of breathing, age, and degree of wellness.
Which action made by the nurse during palpation of a patient's skin would require follow up from the charge nurse quizlet?which action made by the nurse during palpation of a patient's skin would require follow-up from the charge nurse? c. checking thickness with the palmar surface of hand. the nurse would require follow up from the charge nurse if he or she checked turgor and elasticity by using the dorsum of the hand.
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Which action made by a nurse during psychological preparation of a patient before a physical examination can limit the patients communication ability?
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