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NUR 104 Module I Health Assessment And Physical Examination Questions And Answers
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NUR 104 Module I Health Assessment And Physical Examination Questions And Answers
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NUR 104 Module I Health Assessment And PhysicalExamination Questions And Answers
purpose of physical examination ANS gather baseline information about a patient's health status,
supplement/confirm/refute information learned during the history taking, identify or confirm nursing diagnoses,
make clinical judgements about a patient's current or changing health status and ability to manage it, evaluate the
outcomes of care
cultural sensitivity ANS culture influences a patient's behavior, consider health benefits, use of alternative
therapies, nutritional habits, relationships with family and person comfort zone, avoid stereotyping and gender bias
skills of physical assessment ANS inspection, palpation, percussion, auscultation, olfaction
organization of the examination ANS assessment of each body system, note subjective behavior, systematic and
organized, head-to-toe approach
assess the skin ANS nursing history, color, moisture, temperature, texture, turgor or pallor, vascularity, edema,
lesions
condition of nails reflects ANS general health, state of nutrition, occupation, level of self care
assess the mouth and pharynx ANS lips, mouth, gums (color, hydration, lesions), teeth
assess the ears ANS auricles: texture, tenderness, swelling, lesions, color, pain, cerumen
assess the head ANS inspect position, size, shape, contour, facial symmetry, palpate skull (size, shape, contour)
nursing history of the thorax and lungs ANS persistent cough, productive or non productive, shortness of breath,
orthopnea, dyspnea, tobacco use
assess the heart ANS inspection and palpation, patient must be relaxed and comfortable, PMI (point of maximal
impulse), S1 and S2 heart sounds, capillary refill time
level of consciousness ANS awake, alert, drowsy, lethargic, comatose
, orientation ANS person: know their name
place: knows where they are
time: knows date or season
orientation: x3
what does a comprehensive physical examination involve? ANS inspection, palpation, percussion, auscultation,
and olfaction
inspection ANS the use of vision to distinguish normal from abnormal findings
what should you inspect each area for during a physical examination? ANS size, shape, color, symmetry,
position, and abnormalities
palpation ANS involves the use of hands to touch body parts and make sensitive assessments
what changes during a physical examination when examining the abdomen? ANS you auscultate before you
palpate unlike everything else
what do you palpate the skin for? ANS temperature, moisture, texture, turgor, tenderness, and thickness
what do you palpate the abdomen for? ANS tenderness, distention, or masses
what do you palpate last? ANS tender areas
what do you need to palpate? ANS warm hands, short fingernails, and a conscious effort to have a gentle
approach
what parts of the hand should you use to determine position, texture, size, consistency, masses, fluid, and pulsation
during palpation? ANS most sensitive parts (the palmar surface of the fingers and finger pads)
what parts of the hand should you use to assess temperature during palpation? ANS the dorsal surface or back of
the hand
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