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REGIS NU 650 FINAL EXAM
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REGIS NU 650 FINAL EXAM
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Page 1 of 79REGIS NU 650 FINAL EXAM 2024-2025
Which illustrates the nurse using the technique of inspection?
The nurse detects a fruity odor of the patient's breath. The nurse notes increased
warmth surrounding the patient's incision. The nurse notes a rhythmic lub-dub
over the patient's anterior thorax. The nurse detects tympany over the patient's
lower abdomen. - answer-Inspection involves conscious observation of the
patient's physical characteristics and behaviors and smelling for odors. The nurse
uses the technique of inspection to detect a fruity odor to the patient's breath.
The nurse uses the technique of palpation to note increased warmth surrounding
an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the
heart. The nurse detects tympanic sounds of the bowel by percussing the
abdomen.
Order of Assessment - answer-Inspection, Palpation, Percussion and Auscultation.
EXCEPT with abdomen
Comprehensive Health History - answer-chief complaint, reason for visit, ROS,
past medical and surgical history, social history and family history
Which of the following techniques are used in a physical assessment? Select all
that apply.
Inspection Palpation Auscultation Questioning Subjectivity - answer-The four
techniques of inspection, palpation, percussion, and auscultation form the basis
for physical assessment. Subjectivity and questioning are distracters for this
question.
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Pediatric Body measurements - answer-length, height, weight, head
circumference fro birth to 36 months
Normal/Hypertension cut off - answer-<130 normal 140+ hypertension
Fontanel Closure - answer-posterior 1-2 months, anterior 9mo-2years
otoscope - answer-adult-up and back, peds- down and back, using largest
speculum that will fit comforably
tympanic membrane - answer-Cone of light R-5 l-7
EOM testing - answer-CN III, IV, VI
AP diameter of chest - answer-1:2 (AP less than transverse)
barrel chest - answer-COPD
Flat or Dull percussion - answer-effusion or pneumonia
normal resonant percussion - answer-healthy lung
Hyperressonance (percussion) - answer-trapped air
crackles/rales - answer-high pitched, discontinuous
, Page 3 of 79
Wheezes - answer-high-pitched whistling or squeaking sounds during inspiration
or expiration
Rhonchi - answer-snoring, rumbling sounds heard upon auscultation of the chest
during respiration-low pitched
tactile fremitus - answer-• INCREASED FREMITUS
- Means there is liquid or solid inside the lungs (consolidation such as with
pneumonia)
- Remember Liquid or solid transmits vibrations better than air
• DECREASED FREMITUS
Means air trapping such as with emphysema or bronchial obstruction.
Bronchophony - answer-the spoken voice sound heard through the stethoscope,
which sounds soft, muffled, and indistinct over normal lung tissue, clearer over
disease
Egophony - answer-abnormal change in tone of voice that is heard when
auscultating the lungs EE-->AA
UE Arteries - answer-radial-thumb side, ulnar pinky side
Pulse grading - answer-0 absent
1+ weak
, Page 4 of 79
2+ normal
3+ increased
4+ bounding
palpate bilaterally
PMI - answer-point of maximal impulse mid-clavicular and 5th ICS
S1 - answer-normal, closure of AV, Start of systole, loudest at Apex, contraction of
ventricles
S2 - answer-normal, closure of semilunar, end of systole, loudest at base, filling of
ventricles
S3 - answer-third heart sound (normal in pregnant young adults, and children),
gallop
S4 - answer-extra heart sound, end of diastole, indicative of disease-AFIB
murmur grading scale - answer-I-Barely Audible
II-Quiet, Clearly Audible
III-moderately Loud
IV-loud, thrill
V-Very loud, can palpate thrill
VI-Very loud, thrill palpable and visible
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