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NUR 120 Exam #2 Questions with Complete Answers
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NUR 120 Exam #2 Questions with Complete Answers
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NUR 120 Exam #2 Questions withComplete Answers
When percussing the liver, what should you hear? - Answer-Dullness
What is a Health assessment? - Answer-a comprehensive assessment of the physical,
mental, spiritual, socioeconomic, and cultural status of an individual, group, or
community.
What are the purposes of health assessment? - Answer-Health history & physical
assessment (and lab work)
What is a health history? - Answer-a collection of subjective data that provide info abt
the pt's health status.
What is a physical assessment.(aka physical examination)? - Answer-a collection of
objective data that provides info abt changes in the pt's body systems
What is a nursing assessment? - Answer-Focus on the patient's functional abilities and
physical responses to illness and other stressors.
What are the different types of nursing physical examination? - Answer--Focused
-Comprehensive
-Ongoing partial
-System-specific
-Emergency
What is a focused examination? - Answer--to assess a presenting problem
-ex. the ER RN assesses the pt complaining of (c/o) chest pain (CP)
What is a comprehensive examination? - Answer--pt interview plus complete head-to-
toe examination
-ex.the cardiac RN performs an admission history and physical (H&P) on a newly
admitted pt to the telemetry unit
What is an ongoing partial examination? - Answer--conducted at regular intervals
-ex. the cardiac RN continues to monitor the newly admitted pt on the telemetry unit
every 4 hrs
What is a system-specific examination? - Answer--to assess one body problem
-ex. the newly admitted pt now c/o abdominal pain and heartburn, so the cardiac RN
performs a GI examination on the telemetry unit.
,What is an emergency examination? - Answer--to determine life-threatening or unstable
conditions
-ex. the hospital ER trauma team is working on a pt who is in cardiac arrest after being
brought in by an ambulance following a car crash
What do you include when documenting health history? - Answer--Biographical data
(i.e. name, DOB, gender, race)
-Chief complaint
-History of present illness (HPI)
-Past medical history (PMH)
-Past surgical history (PSH)
-Family history (FH)
-ROS
-Functional health patterns
-Psychosocial and lifestyle factors
What are you assessing for when auscultating? - Answer--assessing the four
characteristics of sound, that is, pitch, loudness, quality, and duration
-ex. heart sounds, lung sounds, and abdomen.
-Pitch: ranging from high to low.
-Loudness: ranging from soft to loud.
-Quality: i.e. gurgling or swishing.
-Duration: short, medium, or long.
What are you assessing for when inspecting? - Answer--assessing size, color, shape,
position, and symmetry
-ex. compares bilateral body parts
What are you assessing for when palpating? - Answer--assessing mobility, moisture,
pulsation, shape, size, skin turgor, temperature, texture, tenderness, and vibrations.
What are you assessing for when percussion? - Answer--assessing location, shape,
size, and density of tissues.
The nurse would be able to gather the most complete data about a patient's pedal
edema using the assessment skill of:
a. inspection.
b. palpation.
c. percussion.
d. auscultation. - Answer-B
An emaciated patient complains of thirst and headache. Upon physical examination, the
nurse finds that the skin does not return to normal shape; thus, consistent with:
a. pallor.
, b. edema.
c. erythema.
d. poor skin turgor. - Answer-D
What is the normal capillary refill time? - Answer-Less than 3 seconds
How do you assess skin turgor? - Answer--a small fold of skin is picked up and then
released to return to its normal shape.
-difficulty in lifting a skin fold may indicate presence of edema
What is the ABCDE System of Melanoma detection? - Answer--Asymmetry: moles that
have asymmetrical appearance
-Border: a mole that has a blurry and or jagged edges
-Color: a mole that has more than one color
-Diameter: moles with a diameter larger than a pencil eraser
-Evolution: a mole that has gone through sudden changes in size, shape, or color
What is the sinus in the head that you cannot palpate? - Answer--sphenoid
What is the sinus between the frontal and maxillary sinus? - Answer--ethmoid
When percussing the chest, what sound would the nurse expect to hear over the lungs?
a. Dullness
b. Tympany
c. Resonance
d. Hyperresonance - Answer-C
When percussing the abdomen, what should you hear? - Answer-Tympany
What are adventitious breath sounds? - Answer-Abnormal breath sounds heard during
auscultation of the lung fields which may include crackles, wheezes or rhonchi
Where is the point of maximal impulse (PMI) located? - Answer--Fifth intercostal space,
left midclavicular line.
The nurse is palpating the client's lymph nodes 1" above the elbow. This site is best for
assessing:
a. epitrochlear nodes.
b. axillary lymph nodes.
c. cervical lymph nodes.
d. inguinal lymph nodes. - Answer-A
What is the correct order of assessing for an abdominal exam? - Answer-1. Inspection
2. Auscultation
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