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Physical Assessment Final Exam
Physical Assessment Final Review
Terms in this set (197)
Female gender, age > 50
Personal history of breast cancer
Mutation of BRCA1 & BRAC2 genes
First-degree relative with breast cancer (mother, sister, daughter)
High breast tissue density
Biopsy-confirmed atypical hyperplasia
High-dose radiation to chest
Early menarche (<12 yrs) or late menopause (>55 yrs)
breast cancer risk factors
Change in breast size or shape.
Skin dimpling or skin changes (eg, thickening, swelling, or redness)
Recent nipple inversion
breast cancer assessment findings
vertical strip method
what is the proper technique for palpating breasts?
axillary lymph nodes
What other part of the body is relevant for assessment of breast?
about 3 to 5 days after your period starts
The best time to do a monthly self-breast exam is?
how often should you perform a BSE?
the production of breast milk in a women who is not breastfeeding
development of breast tissue in males
inflammatory condition of the breast usually caused by a bacterial infection
red, edematous, tender, warm to the touch and hard breasts
acute streptococcal or staphylococcal infection of the skin and subcutaneous tissue.
Usually develops after break in skin
Red, hot, bacterial, usually caused by a break in the skin
a tool used to measure the thickness of subcutaneous fat
an ultraviolet light used to detect fungal infections on the skin and corneal abrasions of the eye
basic screening for hearing acuity
what does the Ophthalmoscopic Exam look for?
instrument used for visual examination of the ear
A device that amplifies sounds that are difficult to hear with an acoustic stethoscope
when you can't feel pedal pulses
When does a nurse need to use a doppler?
dorsal side of the hand
how do you assess skin temperature?
knowledge, belief, art, morals, laws, customs, and any other capabilities and habits acquired by a person as a member of society
cultural desire, cultural awareness, cultural knowledge, cultural skills, & cultural encounters
5 components of providing culturally competent care?
questions that allow respondents to answer however they want
questions that can be answered in short or single word responses
measures designed to prevent the transmission of organisms and used for all patients in healthcare facilities regardless of diagnosis or infection status
the single most important means of preventing the spread of infection
S1; Ventricles contract creating pressure that closes AV valves, preventing backflow of blood into atria
S2; Ventricles relax and fill with blood from left and right atria; closing of semilunar valves
lowest temperature in the morning and highest in the late afternoon
normal variations in temperature
96.4F to 99.1°F
Expected temperature ranges from ...
factors that may increase BP
Pt's arm above heart level
Cuff too big
Not inflating the cuff enough
Deflating too rapidly (faster than 2-3 mm Hg per second)
Pressing diaphragm of stethoscope too firmly on brachial artery
Errors Resulting in False-Low BP Readings
Pt's legs crossed
Pt's arm below heart
Cuff too small
Cuff wrapped loosely or unevenly
Deflating too slowly (slower than 2-3 mm Hg per second)
Reinflating without completely deflating
Not waiting 1-2 minutes before obtaining a repeat measurement
Errors Resulting in False-High BP Readings
In the last year, how often did anyone:
Hurt you physically?
Insult or talk down to you?
Threaten you with physical harm?
Scream or curse at you?
how to screen for interpersonal violence
How have you been feeling about yourself?
ask about feelings of hopelessness or thoughts of harming themselves or others
how to screen for mental health?
Certified translator should be used
Best practice for non-English-speaking patients?
What cultural practices are important to you?
What language is spoken in your home?
What are some of the practices you believe will improve your health?
Do you use alternative healing methods?
Are there any special types of food that are forbidden by your culture?
Ask about a patient's health beliefs and practices that may reflect his or her cultural heritage.
important questions to ask during a cultural assessment
We need to understand that people can be in the same culture and have _______________-
has recent onset (< 6 mo.) (ex: just had an abdominal surgery 8 hr ago) and results from tissue damage, is usually self-limiting, and ends when tissue heals
may be intermittent or continuous pain lasting more than 6 months.
Clinical manifestations are not those of physiologic stress because patient adapts to pain
When hands are not visibly soiled
when to use alcohol based hand rub vs soap and water for hand hygiene?
BMI <18.5 = underweight
BMI 18.5-24.9 = normal BMI
BMI 25-29.9 = overweight
BMI 30-34.9 = obesity class 1
BMI 35-39.9 = obesity class 2
BMI >40 = extreme obesity
pupils dilate when looking at distant object and constrict when looking at near object
Pupils are Equal and Round and React to Light and Accommodation
what is PERRLA?
CN III- Oculomotor, CN IV - Trochlear and CN VI- Abducens
what does the 6 Cardinal Fields of Gaze test?
CN I - Olfactory
Test nose for smell
CN II - Optic
ophthalmoscopic examination of eyes
CN III- Oculomotor
CN IV- Trochlear
Extraocular muscle movement (EOM)
6 cardinal fields of gaze
CN V- Trigeminal nerve
Movement of jaw and sharp/dull sensation
CN VII - Facial nerve
tests for movement - Have patient raise eyebrows, purse lips, close eyes tightly against resistance, show teeth, smile, and puff out cheeks
CN VIII - Acoustic
CN IX - glossopharyngeal
taste and gag reflex
CN X - Vagus
Inspect oropharynx for gag reflex and soft palate movement
Open mouth and say "ah"
CN XII - Hypoglossal
Inspect tongue for movement, symmetry, strength, absence of tumors
Have the patient protrude tongue, move toward nose, chin, side to side.
CN XI - Spinal Accessory
Test shoulder and neck muscles for strength and movement
Have patients shrug shoulders and turn head to side against hands.
Test cerebellar function for balance and coordination
What does the Romberg test test for?
by examiner moving finger and toe up and down.
Patient should be able to tell you the position
Yellowing of the sclera may indicate
inadequate oxygenation of tissues
cyanosis or pallor noted may indicate
Elevated, circumscribed, superficial
Filled with serous fluid
Less than 1 cm in diameter
Ex. Varicella (chickenpox), herpes zoster (shingles), impetigo
Similar to vesicle but filled with purulent fluid
Ex. Acne, folliculitis, herpes simplex
Less than 1 cm diameter
Ex. Wart, mole, cherry angioma, skin tag
Elevated and solid
Deeper in dermis
Greater than 2 cm in diameter
Ex: neoplasms, lipoma, hemangioma
pinpoint purple or red spots from minute hemorrhages under the skin
Less than 1 cm in diameter
Ex: flat moles, freckles
layer of skin with NO direct blood supply
regulates water loss
highly vascular connective tissue
regulation of body temperature
contains sensory nerve fibers
60-100 beats per minute
Normal pulse rate
auscultate apical pulse for one full minute
If pulse rhythm is irregular...
Bean-shaped filters that cluster along the lymphatic vessels of the body. They function as a cleanser of lymph as wells as a site of T and B cell activation
submental lymph node located
midline under the chin
submandibular lymph node located
along base of mandible
preauricular lymph node located
in front of the ear
postauricular lymph node located
behind the ear
Supraclavicular lymph node located
just above and behind the clavicle, at the sternomastoid muscle
sign of infection
if lymph nodes are enlarged, tender or immobile, this might be a...?
Loss of epidermis
Linear hollowed-out crusted area
Ex. Abrasion or scratch
order of abdomen assessment techniques:
if a bruit is heard during auscultation of the abdominal aorta, this suggests?
Normoactive bowel sounds
5-35 per minute
Bell of stethoscope
Used to hear soft, low-pitched sounds such as extra heart sounds or vascular sounds (bruit)
Diaphragm of stethoscope
Used to hear high-pitched sounds (breath sounds, bowel sounds, and normal heart sounds)
angled toward nose to project sound toward tympanic membrane
How do you place the ear pieces of the stethoscope in the ear?
Pads of fingers and depress 1-2 cm
what is light palpation?
Palpate abdomen deeply for tenderness, masses, enlarged organs, and aortic pulsation.
what is deep palpation?
Air conduction > bone conduction
Expected normal findings when completing the Rinne test (tuning fork)
Have patient cough first and see if sound is changed or disappeared
What do you do if you hear abnormal breath sounds?
vesicular breath sounds
peripheral lung fields (Insp>exp)
bronchial breath sounds
over trachea (Insp<exp)
bronchovesicular breath sounds
near sternum (Insp=exp)
pt having difficulty breathing
What does the tripod position indicate to a nurse conducting an assessment?
Refusing to eat.
Other symptoms of protein-calorie malnutrition.
Recurrent binge-and-purge eating cycles.
Chronic irritation or erosion of the pharynx, esophagus, and teeth (from exposure to hydrochloric acid).
anorexia, insomnia, hopelessness, weight loss, fatigue
Expected findings for patients with depression
in patients with a history of mental illness, pain tolerance would be ________
Hemoptysis !!!! (rust colored sputum)
Low grade fever
Night sweats !!!!
signs of tuberculosis
Full range of motion both actively and passively, joint stability with no tenderness, heat, edema, crepitus, deformity or contracture
Expected findings when assessing range of motion for knees, hips, shoulders in healthy adult
Sensation before a seizure
Time of seizure
After seizure complete
Person may be tired, confused, nauseated, may have amnesia
If multiple seizures occur in short time, the time between seizures
Affects weight-bearing joints
Affects joints with repetitive movement
As cartilage wears away, bones move against each other (joint inflammation)
Symptoms include joint edema and aching pain.
Joint deformities of fingers develop:
Heberden's nodes in distal interphalangeal joints.
Bouchard's nodes in peripheral interphalangeal joints.
Gets worse with movement
clinical findings of osteoarthritis
A chronic, autoimmune inflammatory disease of connective tissue.
Onset is usually gradual with fatigue, morning stiffness, diffuse muscle ache, and weakness.
Synovial lining inflamed with deterioration of cartilage and erosion of surfaces (spurs).
Joint involvement is bilateral.
Symptoms are pain, edema, and stiffness of fingers, wrists, ankles, feet, and knees.
Symptoms get better with movement
clinical findings of rheumatoid arthritis
Connects muscle to bone
Connect bone to bone
Areas where two or more bones join together
A connective tissue that is more flexible than bone and that protects the ends of bones and keeps them from rubbing together.
Support for soft tissues and organs.
Protection of organs—brain and spinal cord.
Body movement and hematopoiesis.
Continual remodeling and changing collagen and mineral composition to accommodate stress placed upon them.
functions of bones
large, flat triangular bone
What type of bone is the scapula
What type of bones are the humerus and femur
Right lung has three lobes and the left has two
number of lobes in the lungs
liver and gallbladder
organs in the right upper quadrant
body of the pancreas
organs in the left upper quadrant
cecum and appendix
organs in the right lower quadrant
sigmoid colon and rectum
organs in the left lower quadrant
listen to your lungs for signs of fluid buildup (lung congestion) & your heart for whooshing sounds (murmurs)
examine the veins in your neck and check for peripheral edema
Where and how do you assess heart failure
Largest part of the brain; responsible for voluntary muscular activity, vision, speech, taste, hearing, thought, and memory.
frontal lobe function
awareness of self
voluntary motor activity
parietal lobe function
to receive sensory input such as position sense, touch, shape, and texture of objects
temporal lobe function
primary auditory and olfaction
wernicke's (L side): meaningful speech, verbal/general memory, understanding language
interpret others' emotions/reactions (rear part)
occipital lobe function
responsible for receiving and interpreting visual information
controls all of your involuntary functions
coordinating movement, equilibrium, muscle tone and proprioception
complete range of motion with gravity
muscle strength grading 3/5
complete range of motion against gravity with some resistance
muscle strength grading 4/5
complete range of motion against gravity and full resistance
muscle strength grading 5/5
What percussion tone is heard over organs (liver)
What is the most common percussion tone heard (high-pitched and hollow-quality)
What percussion tone is heard in overinflated lungs, as in emphysema
Done when patient reports flank pain
To detect CVA tenderness
What is direct percussion of the costovertebral angle used for?
Pain: Steady, boring, dull, or sharp; radiates from epigastrium to back.
Patients prefer fetal position with knees to chest.
Nausea and vomiting.
assessment findings for pancreatitis
Primary symptom is right upper quadrant colicky pain that may radiate to mid-torso or right scapula.
Indigestion and mild transient jaundice
assessment findings for cholecystitis
Positive psoas sign
assessment findings for appendicitis
Physical appearance // Hygiene
Body structure and movement
Emotional and mental status & Behavior
components of general inspection
Focused or Problem-Oriented Assessment
type of health history that includes data limited to the scope of the problem.
Aortic valve - second ICS, RSB
Pulmonic valve - second ICS, LSB
Erb's point - third ICS, LSB
Tricuspid valve - fourth ICS, LSB
Mitral valve/apical pulse - fifth ICS, midclavicular line
5 points to osculate during the cardiovascular assessment
apical pulse, Mitral, 5th ICS, MCL
where is the point of max impulse
Tricuspid valve on right
Mitral valve on left
location of AV valves
superior and inferior vena cava
brain and kidneys
Blood flow through the heart
Arteries = oxygenated blood, away from heart
Veins = deoxygenated blood, toward the heart, contains valves
veins vs arterial circulation
patient flexes and you try to straighten arm
Test Arm Muscle Strength: biceps
patient extends while you resist and push it to flexed position
Test Arm Muscle Strength: triceps
patient tries to extend leg and you put pressure against
Test leg muscles for strength: Quadriceps
groove between biceps and triceps muscle in the bend of the elbow
posterior tibialis pulse
Inner aspect of ankle below and slightly behind the medial malleolus (ankle bone)
dorsalis pedis pulse
Palpate lightly over dorsum of foot between tendons of first and second toes.
young men ages 20-34
history of testicular cancer in other testicle
Who is at risk for testicular cancer?
sudden onset testicular pain and scrotal swelling
the hallmark finding of testicular torsion is ...
confusion. changes in mood. memory problems
Urgent findings to report to a provider following a head trauma
pitting edema scale: barely perceptible pit, 2mm
pitting edema scale: deeper pit, rebounds in a few seconds, 4mm
pitting edema scale: deep pit, rebounds in 10-20 seconds, 6mm
pitting edema scale: deeper pit, rebounds in >30 seconds, 8mm
right sternal border, 2nd intercostal space
where to listen for aortic stenosis?
Look for accessory muscle use, retractions
5 on front, 4 on back auscultating minimum
How to assess respiratory system?
Proteins: meat, fish, poultry, milk, eggs
Carbohydrates: sugar-sweetened beverages, candy, desserts
what are the three macronutrients
vitamins and minerals
Intense episodes of excruciating unilateral pain.
Pain is burning, drilling, stabbing behind one eye.
May be accompanied with unilateral ptosis, ipsilateral lacrimation, nasal stuffiness, and drainage.
Starts with aura from vasospasm of intracranial arteries; throbbing unilateral distribution of pain.
nausea, vomiting, and photophobia.
downward sloping 90 degrees
costovertebral angle should be...
yellow or green
color of nasal drainage with an infection
Paroxysmal Nocturnal Dyspnea
sudden awakening from sleeping with shortness of breath
excessive urination at night
bending a joint
Straightening of a joint
dorsiflexion and plantar flexion
up and down movement of the foot
asymmetry, border, color, diameter, evolving
ABCDE of skin cancer
Stage 1 pressure ulcer
intact skin with nonblanchable redness
Stage 2 pressure ulcer
partial thickness skin loss involving epidermis, dermis, or both
Stage 3 pressure ulcer
Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon.
Stage 4 pressure ulcer
Full-thickness tissue loss with exposed bone, muscle, or tendon
unstageable pressure ulcer
base of ulcer covered by slough and/or eschar in the wound bed.
injuries to the ligaments around a joint
overstretching and tearing a muscle
can't think of the words to say
what they are receving doesn't make sense
normal with deep palpation
abnormal with light palpation
Aortic pulsation with deep palpation- normal or abnormal?
talk calm, cool, relaxed, talk therapeutically to them
how should you talk to an anxious patient?
Shouldn't be able to see tonsils, NO white exudate, smooth appearance
normal assessment findings for the tonsils
sign of liver failure
Barrel chest, pursed lip breathing, pink puffer, tripod position
hyperreactive airway disease characterized by:
Cyanosis, sputum, productive cough
Frothy sputum, going to the bathroom at night a lot, bounding pulses, edema, dyspneic, tachypnea
heart failure characteristics
diminished or absent breath sounds, dyspnea
breath sounds present with a pleural effusion
peripheral artery disease
decreased or absent pulses
tips of toes, foot or lateral malleolus
rounded, smooth, "punched out"
black eschar or pale pink granulation
dependent rubor, elevation pallor
thin, shiny, taut
loss of hair on legs
peripheral vascular disease
present pulses, may be difficult to palpate w edema
near medial malleolus
yellow slough or dark red, "ruddy" granulation
skin thick, hardened and indurated
protection to prevent occurrence of disease
immunizations, pollution control, nutrition, exercise
early identification of disease before it becomes symptomatic to halt the progression of the pathologic process
screening examinations and self-examination practices
minimize severity and disability from disease through appropriate therapy for chronic disease
diabetes mellitus management
a crackling or grating sound usually of bones
pain or discomfort in center of chest and shortness of breath, cold sweat, nausea, vomiting, or lightheadedness.
symptoms of MI in women
worst chest pain ever experienced, pain lasts longer than 5 minutes.
May radiate to left shoulder, jaw, arm, or other areas of chest; it is not relieved by rest or nitroglycerin.
symptoms of MI in men
smoking, obesity, sedentary lifestyle, atherosclerosis, stress
Risk factors of cardiovascular disease:
painful when they breathe in and out
Angina vs Pericarditis
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