Health Assessment and Physical
Examination 2022
List the five nursing purposes for performing a physical assessment. (5) - Answer- a.
Gather baseline
... [Show More] data about the patient's health status
b. Support or refute subjective data obtained in the nursing history
c. Confirm and identify nursing diagnoses
d. Make clinical judgments about a patient's changing health status and
management
e. Evaluate the outcomes of care
List the principles related to the nurse performing daily physical examinations. (4) -
Answer- a. A head-to-toe assessment is required daily
b. Reassessment is performed when the patient's condition changes as it improves
or worsens
c. The environment, equipment, and patient are properly prepared
d. Safety for confused patients should be a priority
Proper preparation for examination should include: (5) - Answer- a. Infection control
b. Environment
c. Equipment
d. Physical preparation of the patient
e. Psychological preparation of the patient
List seven variations in the nurse's individual style that are appropriate when
examining children. (7) - Answer- a. Gather all or part of the histories of infants and
children from parents
b. Perform the examination in a nonthreatening are and provide time for play
c. Offer support to the parents during the examination and do not pass judgment
d. Call children by their first names and address their parents as Mr. and Mrs.
e. Use open-ended questions to allow parents to share more information
f. Treat adolescents as adults
g. Provide confidentiality for adolescents; speak alone with them
List seven variations in the nurse's individual style that are appropriate wen
examining older adults. (7) - Answer- a. Do not stereotype about aging patients's
level of cognition
b. Be sensitive to sensory or physical limitations (more time)
c. Adequate space is needed
d. use patience, allow for pauses, and observe for details
e. Certain types of information may be stressful to give
f. Perform the examination near bathroom facilities
g. Be alert for signs of increasing fatigue
Identify the principles to follow to keep an examination well organized. (7) - Answera. Compare both sides for symmetry
b. If a patient is ill, first assess the systems of the body part most at risk
c. Offer rest periods if the patient becomes fatigued
d. Perform painful procedures near the end of the examination
e. Record assessments in specific terms in the record
f. Use common and accepted medical terms and abbreviations
g. Record quick notes during the examination to avoid delays
Define inspection. - Answer- Looking, listening, and smelling to distinguish normal
from abnormal findings
Identify the guidelines to achieve the best results during inspection. (6) - Answer- a.
Adequate lighting is available
b. Use direct light source
c. Inspect each area for size, shape, color, symmetry, position, and abnormality
d. Position and expose body parts as needed, maintaining privacy
e. Check for side-to-side symmetry
f. Validate findings with the patient
Define palpation - Answer- Using the hands to touch body parts.
Light palpation - Answer- Pressing inward 1 cm (surperficial)
Deep palpation - Answer- Depressing the area 4 cm to assess the conditions of
organs.
Define auscultation - Answer- Listening to the internal sounds the body makes.
Auscultating sounds: Frequency - Answer- Frequency indicates the number of sound
wave cycles generated per second by a vibrating object
Auscultating sounds: Amplitude - Answer- Loudness, soft to loud
Auscultating sounds: Quality - Answer- Sounds of similar frequency and loudness
Auscultating sounds: Duration - Answer- Length of time that sound vibrations last
List at least 12 specific observations of the patient's general appearance and
behavior that should be reviewed. (12) - Answer- a. Gender and race
b. Age
c. Signs of distress
d. Body type
e. Posture
f. Gait
g. Body movements
h. Hygiene and grooming
i. Dress
j. Body odor
k. Affect and mood
l. Speech
Identify some signs of patient abuse. - Answer- Physical injury or neglect are signs of
possible abuse (evidence of malnutrition or presence of bruising). Also watch for fear
of the spouse or partner, caregiver, or parent.
Identify the questions related to the following acronym.
CAGE - Answer- C: Have you ever felt the need to cut down on your use?
A: Have people annoyed you by criticizing your use?
G: Have you ever felt bad or guilty about your use?
E: Have you ever used or had a drink first thing in the morning as an "eye opener" to
steady your nerves or feel normal?
List three actions that should be taken to ensure accurate weight measurement of a
hospitalized patient. (3) - Answer- a. Weigh patients at the same time of day
b. Weigh patients on the same scale
c. Weigh patients in the same clothes
Assessment of the skin reveals the patient's health status related to: (5) - Answer- a.
Oxygenation
b. Circulation
c. Nutrition
d. Local tissue damage
e. Hydration
List the risks for skin lesions in hospitalized patients. (9) - Answer- A. Exposure to
pressure during immobilization
b. Various medications
c. Neurologic impairment
d. Chronic illness
e. Orthopedic injury
f. Diminished mental status
g. Poor tissue oxygenation
h. Low cardiac output
i. Inadequate nutrition
Define pigmentation. - Answer- Pigmentation is skin color. It is usually unifrom over
the body
Color: Cyanosis
Condition: ?
Causes: ?
Assessment Locations: ? - Answer- Condition: Increased amount of deoxygenated
hemoglobin (associated with hypoxia)
Causes: Heart or lung disease, cold environment
Assessment Locations: Nail beds, lips, mouth, skin (severe cases)
Color: Pallor
Condition: ?
Causes: ?
Assessment Locations: ? - Answer- Condition: Reduced amount of oxyhemoglobin
resulting from decreased blood flow
Causes: Anemia, shock
Assessment Locations: Face, lips, conjunctivae, nail beds, palms of hands
Color: Loss of pigmentation
Condition: ?
Causes: ?
Assessment Locations: ? - Answer- Condition: Vitiligo
Causes: Congenital or autoimmune condition causing lack of pigment
Assessment Locations: Patchy areas on skin over face, hands, arms
Color: Jaundice
Condition: ?
Causes: ?
Assessment Locations: ? - Answer- Condition: Increased deposit of bilirubin in
tissues
Causes: Liver disease, destruction of red blood cells
Assessment Locations: sclera, mucous membranes, skin
Color: Erythema
Condition: ?
Causes: ?
Assessment Locations: ? - Answer- Condition: Increased visibility of oxyhemoglobin
caused by dilation or increased blood flow
Causes: Fever, direct trauma, blushing, alcohol intake
Assessment Locations: Face, area of trauma, sacrum, shoulders, other common
sites for pressure ulcers
Color: Tan-brown
Condition: ?
Causes: ?
Assessment Locations: ? - Answer- Condition: Increased amount of melanin
Causes: Suntan, pregnancy
Assessment Locations: Areas exposed to sun: face, arms, areolae, nipples
Identify the physical findings of the skin that are indicative of substance abuse. (8) -
Answer- a. Diaphoresis
b. Spider angiomas
c. Burns (especially on fingers)
d. Needle marks
e. Contusions, abrasions, cuts, scars
f. "Homemade" tattoos
g. Vasculitis
h. Red, dry skin
Turgor - Answer- Skin's elasticity
Edema - Answer- Areas of the skin that are swollen or edematous from a buildup of
fluid in the tissues
Senile keratosis - Answer- Thickening of the skin
Cherry angiomas - Answer- Ruby-red papules
Macule - Answer- Flat, non palpable change in skin color; smaller than 1 cm (e.g.
freckle, petechiae)
Papule - Answer- Circumscribed, solid elevation in skin; smaller than 1 cm (e.g.
elevated nevus)
Nodule - Answer- Elevated solid mass, deeper and firmer than papule; 1-2 cm (e.g.
wart)
Tumor - Answer- Solid mass that extends deep through subcutaneous tissue; larger
than 1-2 cm (e.g. epithelium)
Wheal - Answer- Irregularly shaped, elevated are or superficial localized edema;
varies in size (e.g. hive, mosquito bite)
Vesicle - Answer- Circumscribed elevation of skin filled with serous fluid, smaller tha
1 cm (e.g. herpes simplex, chickenpox)
Pustule - Answer- Circumscribed elevation of skin similar to vesicle but filled with
pus; varies in size (e.g. acne, staphylococcal infection)
Ulcer - Answer- Deep loss of skin surface that extends to dermis and frequently
bleeds and scars; varies in size (e.g. venous stasis ulcer)
Atrophy - Answer- Thinning of skin with loss of normal skin furrow, with skin
appearing shiny and translucent; varies in size (e.g. arterial insufficiency)
Basal cell carcinoma - Answer- 0.5- to 1-cm crusted lesion that is flat or raised and
has a rolled, somewhat scaly border
Frequently appearance of underlying, widely dilated blood vessels within the lesion
Squamous cell carcinoma - Answer- Occurs more often on mucosal surfaces and
nonexposed areas of skin than basal cell
0.5- to 1.5-cm scaly lesion sometimes ulcerated or crusted; appears frequently and
grows more rapidly than basal cell
Melanoma - Answer- 0.5- to 1-cm brown, flat lesion; appears on sun-exposed or
nonexposed skin; variegated pigmentation, irregular borders, and indistinct margins
Ulceration, recent growth, or recent changes in long-standing mole are ominous
signs
Name the three types of lice. (3) - Answer- a. Pediculus humanus capitis (head lice)
b. Pediculus humanus corporis (body lice)
c. Pediculus pubis (crab lice)
Clubbing - Answer- Change in the angle between the nail and nail base, including
softening, flattening, and enlargement of the fingertips
Beau lines - Answer- Transverse depressions in the nails
Koilonychia - Answer- Concave curves
Splinter hemorrhages - Answer- Red or brown linear streaks in nail beds
Paronychia - Answer- Inflammation of the skin at the base of the nail
Hydrocephalus - Answer- Buildup of cerebrospinal fluid in the ventricles
Acromegaly - Answer- Enlarged jaws and facial bones in adults
Hyperopia - Answer- Visual abnormality. Refractive error causing farsightedness
Myopia - Answer- Refractive error causing nearsightedness
Presbyopia - Answer- Impaired near vision in middle-age and older adults caused by
loss of elasticity of the lens
Retinopathy - Answer- Noninflammatory eye disorder resulting from changes in
retinal blood vessels
Strabismus - Answer- Congenital condition in which both eyes do not focus on an
object simultaneously
Cataract - Answer- Increased opacity of the lens
Glaucoma - Answer- Intraocular structural damage resulting from increased
intraocular pressure
Macular degeneration - Answer- Blurred central vision often occurring suddenly
caused by progressive degeneration of the center of the retina
Examination of the eye includes assessment of five areas. Name them (5) - Answera. Visual acuity
b. Visual fields
c. Extraocular movements
d. External eye structures
e. Internal eye structures
Identify the structures of the external eye that you would inspect. (7) - Answer- a.
Position and alignment
b. Eyebrows
c. Eyelids
d. Lacrimal apparatus
e. Conjunctivae and sclera
f. Corneas
g. Pupils and irises
Exophthalmos - Answer- Bulging of the eye
Ectropion - Answer- Eyelid margin that turns out
Entropion - Answer- Eyelid margins that turn in
Conjunctivitis - Answer- Presence of redness, which indicates an allergy or an
infection
Ptosis - Answer- Abnormal drooping of the eyelid over the pupil
PERRLA - Answer- Pupils equal, round, and reactive to light and accommodation
Identify the internal eye structures that you would examine with an ophthalmoscope.
(6) - Answer- a. Retina
b. Choroids
c. Optic nerve disc
d. Macula
e. Fovea centralis
f. Retinal vessels.............. [Show Less]