Health assessment and physical examination
2022
What is a nursing assessment? - Answer- the systemic gathering of information
related to the physical,
... [Show More] mental, spiritual, socioeconomic, and cultural status of an
individual, group, or community
What is ADPIE (definition and the acronym) - Answer- It is the process for basic
nursing care.
Assess, diagnose, plan, implement and evaluate
What is the A in ADPIE - Answer- Assess
When performing an assessment on a patient, what would you use the acronym
PQRST for - Answer- When assessing pain
what is PQRST - Answer- an acronym used for assessing pain
-P provocative
-Q quality
-R region / radiation
-S severity
-T time
What is AAO? and what would you ask the patient to confirm this? - Answer- Awake
, Alert & Oriented x3
-ask the patient their name, where they are and what day/time
What is the glasglow coma scale? - Answer- it is a tool used to measure a persons
level on consciousness after a brain injury
What is Broca's area? - Answer- motor speech area
*left frontal lobe
What is Wernicke's area? - Answer- language comprehension
What is diaphoresis? - Answer- sweating
can we from symptom to disease or side effect to drug
What is Juandice? - Answer- yellowing of the skin
can be caused because of liver disease, obstruction of bile duct, or excessive
breakdown of RBC
What is cyanosis? - Answer- a bluish discoloration of the skin
can be from poor circulation or inadequate oxygenation of the blood.
What is pallor? - Answer- pale skin
what is ecchymosis - Answer- a discoloration of the skin resulting from bleeding
underneath, typically caused by bruising.
what is petechiae - Answer- round spots under the skin from bleeding
What is spider angiomas? - Answer- swollen blood vessel below skins surface
Whats good, decreased or increased skin turgor ? - Answer- Increased. Decreased
indicated that the patient is dehydrated
What does the ABCD acronym stand for when assessing the patients skin? -
Answer- -Asymmetrical
-Border
-Color
-Diameter
What does the acronym PERRLA mean? - Answer- pupils equal, round, reactive to
light and accommodation
what is a Webers test? - Answer- .Apply vibrating fork to the forehead or on top of
the head... does the patient hear in both ears or just one (Lateralization)
Lateralization - Answer- cognitive function that relies more on one side of the brain
than the other
What do crackeling lung sounds sound like - Answer- short popping sounds.
can be heard during inhalation, expiration, or both
What do wheezing lung sound sound like - Answer- high pitch sounds
-can be heard during inhalation or expiration
What do Rhonchi lunch sounds sound like - Answer- deep course sounds that have
a snoring quality
what do frictional rub lung sounds sound like - Answer- a deep harsh or grating
donut that is usually heard during inhalation
What is S1? - Answer- closure of AV valves, beginning of systole
What is S2? - Answer- closure of semilunar valves, end of systole/ beginning of
diastolic
Dysrythmia - Answer- irregular heart beat
Carotid bruit - Answer- abnormal flow of blood through the carotid artery
-creates blowing swishing sounds
What is lordosis? - Answer- Swayback in the lumbar region (Lumbar, Lordosis)
What is kyphosis? - Answer- Humpback in the thoracic area
What is scoliosis? - Answer- lateral curvature of the spine
what is hypertonicity - Answer- Increased muscle tone (spasticity)
-stiff limb, difficulty moving
What is hypotonicity? - Answer- diminished tone of the skeletal muscles
-floppy limbs/ difficulty standing
What is atrophy? - Answer- decrease in muscle size
muscle is wasting away
Dorsal recumbent position - Answer- lying on the back with the knees flexed
Lithotomy position - Answer- lying on back with legs raised and feet in stirrups
Semi-Fowler's Position - Answer- lying in bed in a supine position with the head of
the bed at approximately 30 degrees.
Fowler's position - Answer- a semi-sitting position; the head of the bed is raised
between 45 and 60 degrees
lateral recumbent - Answer- lying on the side
what is clubbing of nails, what is the cause - Answer- nail bed softening with nail
flattening; often enlargement of finger tips
Cause: chronic lack of oxygen; heart of pulmonary disease
What are beau's lines , what is the cause - Answer- transverse depressions in nails
indicating temporary disturbance of nail growth
cause: systemic illness such as severe infection; nail injury;
What is koilonychia (spoon nail), what is the cause - Answer- curving of the nail
cause: iron deficiency anemia, syphilis, use of strong detergents
What is a splinter hemorrhage, what is the cause - Answer- red or brown linear
streaks in nail bed
cause: minor trams, subacute bacterial endocarditis
What is Paronychia, what is the cause? - Answer- Inflammation of the skin and the
base of the nail
cause: local infection, trauma
What cranial nerves are pure sensory nerves? - Answer- I, II, VIII
What cranial nerves are pure motor nerves? - Answer- III, IV, XI, XII
What cranial nerves are mixed sensory and motor? - Answer- V, VII, IX, X
Glasgow Coma Scale (GCS) >15 - Answer- best response
GCS 8 or less - Answer- comatose patient
GCS 3 - Answer- totally unresponsive
What are the normal breath sounds - Answer- -Vesicular
- Bronchovesicular
-Bronchial
What is the vesicular lung sound - Answer- air moving through smaller airways
what is the bronchovesicular lunch sound? - Answer- air moving through large
airways
What is the bronchial lung sound? - Answer- air moving through the trachea, close
to chest wall.... [Show Less]