Exam (elaborations)
NUR 104 Module I: health assessment and physical examination/Questions and Answers
NUR 104 Module I: health assessment and physical examination/Questions and Answers
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NUR 104 Module I: health assessment andphysical examination/Questions and Answers
purpose of physical examinaton - -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 - -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 - -inspection, palpation, percussion,
auscultation, olfaction
-organization of the examination - -assessment of each body system, note
subjective behavior, systematic and organized, head-to-toe approach
-assess the skin - -nursing history, color, moisture, temperature, texture,
turgor or pallor, vascularity, edema, lesions
-condition of nails reflects - -general health, state of nutrition, occupation,
level of self care
-assess the mouth and pharynx - -lips, mouth, gums (color, hydration,
lesions), teeth
-assess the ears - -auricles: texture, tenderness, swelling, lesions, color,
pain, cerumen
-assess the head - -inspect position, size, shape, contour, facial symmetry,
palpate skull (size, shape, contour)
-nursing history of the thorax and lungs - -persistent cough, productive or
non productive, shortness of breath, orthopnea, dyspnea, tobacco use
-assess the heart - -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 - -awake, alert, drowsy, lethargic, comatose
-orientation - -person: know their name
place: knows where they are
, time: knows date or season
orientation: x3
-what does a comprehensive physical examination involve? - -inspection,
palpation, percussion, auscultation, and olfaction
-inspection - -the use of vision to distinguish normal from abnormal findings
-what should you inspect each area for during a physical examination? - -
size, shape, color, symmetry, position, and abnormalities
-palpation - -involves the use of hands to touch body parts and make
sensitive assessments
-what changes during a physical examination when examining the
abdomen? - -you auscultate before you palpate unlike everything else
-what do you palpate the skin for? - -temperature, moisture, texture, turgor,
tenderness, and thickness
-what do you palpate the abdomen for? - -tenderness, distention, or masses
-what do you palpate last? - -tender areas
-what do you need to palpate? - -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? - -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? - -the dorsal surface or back of the hand
-what part of the hand is more sensitive to vibration during palpation? - -the
palm of the hand
-percussion - -involves tapping the body with the fingertips to produce a
vibration that travels through body tissues
-auscultation - -listening for sounds produced by the body
-what do you need to auscultate? - -good hearing acuity, a good
stethoscope, and knowledge of how to use the stethoscope properly
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