HEALTH ASSESSMENT EXAM 1 (CH. 1,3,4,8,9,10,12,18,27,29) 100% SOLUTIONS ALL CORRECT 2024 UP, Exams of Nursing

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HEALTH ASSESSMENT EXAM 1 (CH.

1,3,4,8,9,10,12,18,27,29) 100% SOLUTIONS

ALL CORRECT 2024 UPDATED GRADED

A+

What does the health history provide? - Solution Subjective and objective data What is subjective data? what is an example? - Solution SD is what the patient tells you Example: headache, chest pain What is objective data? what is an example? - Solution OD are the signs perceived by the examiner through physical examination during assessment Example: rash seen by a nurse, or temp taken with a thermometer In what order are skills performed during a typical assessment? - Solution

1. Inspection
2. Palpation
3. Percussion
4. Auscultation If a patient has abdomen pain, what order do you do the assessment? Why? - Solution 1. Inspection
5. AUSCULTATION
6. Palpation
7. Percussion Because of pain, don't touch or tap the tender area first. Start by inspecting and then listening before you feel the area. What occurs during inspection, the first step? - Solution -ALWAYS COMES FIRST -begins when you first meet a person w/ a general survey -you should start assessment of each body system with inspection

-requires: good lighting, adequate exposure, use of instruments including otoscope, opthalmoscope, penlight, or specula What occurs during palpation, the second step? - Solution Palpation applies sense of touch to assess Can include: temperature, texture, moisture, organ location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, presence of tenderness or pain -use fingers unless taking temperature How can you assess factors during the palpation step? - Solution by using different parts of the hands During palpation, what should fingertips be used to feel? - Solution -best for fine tactile discrimination of skin texture, swelling, pulsation, and determining presence of lumps During palpation, what should fingers and thumb be used for? - Solution - detection of position, shape, and consistency of an organ or mass During palpation, what should the dorsa of hands and fingers be used for? - Solution -best for determining temperature because skin here is thinner than on palms During palpation, what should the base of fingers or the ulnar surface of hand be used for? - Solution -best for vibration **-vibrations are felt on the ulnar side of hand During palpation, what type of palpation should you start with and why? What steps are next? - Solution 1. start with LIGHT palpation to detect surface characteristics and accustom person to being touched -1 cm

2. then deeper palpations when needed -intermittent pressure better than one long continuous palpation -5 to 8 cm or 2-3 in

ALSO: bimanual palpation- requires use of both hands to envelop or capture certain body parts or organs such as kidneys, uterus or adnexa for precise delimitation What occurs during percussion, the third step? - Solution -consists of tapping a person's skin with short, sharp strokes to assess underlying structures What uses does percussion have? - Solution -mapping location and size of organs -signaling density of a structure by a characteristic note -detecting a superficial abnormal mass

1. percussion vibrations penetrate about 5 cm deep
2. deeper mass would give no change in percussion -eliciting pain if underlying structure is inflamed -eliciting deep tendon reflex using percussion hammer HOLLOW (AIR-FILLED) ORGANS SOUND DIFFERENT THAN SOLID ORGANS - Solution What are the two methods of percussion? - Solution 1. Direct, or immediate, which is when the striking hand directly contacts body wall
3. Indirect, or mediate, is when you use both hands and the striking hand contacts stationary hand fixed on person's skin In regards to percussion, what is resonance and where does it occur? - Solution Resonance is low pitch and it occurs over normal lungs In regards to percussion, what is hyperresonant and where does it occur? - Solution Hyperresonant is lower pitch and it occurs over child's lungs In regards to percussion, what is tympany and where does it occur? - Solution Tympany is high pitch and it occurs over air filled organs (stomach, intestines) In regards to percussion, what is dull and where does it occur? - Solution Dull is high pitch and it occurs over solid organs (liver, spleen)

In regards to percussion, what is flat and where does it occur? - Solution Flat is high pitch and it occurs where no air is present such as over muscles/bones or a tumor What occurs during auscultation, the fourth step? - Solution Auscultation is when you listen to sounds produced by the body -most sounds are soft and must be channeled through a stethoscope -once you can recognize normal sounds, you can distinguish the abnormal sounds and "extra" or abnormal sounds What is the single most important step in decreasing microorganism transmission? - Solution WASH YOUR HANDS -before physical contact with each patient -after inadvertent contact with blood, body fluids, secretions, and excretions -after contact with any equipment contaminated with body fluids -after removing gloves What else should you do in health care in addition to washing your hands?

• Solution WEAR GLOVES -any time there is contact with body fluids The nurse is performing an assessment of the abdominal region. What is the appropriate sequence for the examination?

1. Palpation, percussion, inspection, auscultation
2. Inspection, palpation, auscultation, percussion
3. Inspection, auscultation, percussion, palpation - Solution 3 Are vital signs subjective or objective data? - Solution Objective because they can be measured by a health care professional What are the 5 vital signs? - Solution 1. Temperature
4. Pulse
5. Heart rate
6. Respirations
7. Blood pressure What are the benefits of taking temperature orally? - Solution -It is accurate and convenient -The oral sublingual site has a rich blood supply from the carotid arteries that quickly responds to changes in inner core temperature

What is a normal oral temperature range? - Solution 98.6 degrees F ( degrees C) with a range of 96.4 degrees F to 99.1 degrees F (35.8 to 37. degrees C) What is a normal rectal temperature range? - Solution Rectal measures 0.7 to 1 degrees F (0.4 to 0.5 degrees C) higher What is normal temperature influenced by? - Solution -Exercise: moderate to hard exercise increases body temp -Age: wider normal variations occur in infant and young children due to less effective heat control mechanisms; in older adults, temperature usually lower than in other age groups, with a mean of 97.2 degrees F (36. degrees C) In regards to taking a temperature, how long should you wait if the patient has just consumed hot or iced liquids? What about if they just smoked? - Solution Liquids- 15 minutes Smoking- 2 minutes What is a safe and accurate way to take children's temperature? - Solution Axillary temperature When should you take a rectal temperature? - Solution -When other routes are not practical, for example, for comatose of confused persons, persons in shock, or for those who cannot close mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunction or if no tympanic membrane thermometer is available What should you do before inserting the thermometer probe in the rectum?

• Solution -Put on gloves -Use lube How should temperature be recorded? - Solution -In celsius unless agency uses fahrenheit What is the conversion for Fahrenheit to Celsius? Celsius to Fahrenheit? - Solution F to C: C = 59(F-32) or C = F-32+1.

C to F: F = (95 x C) + 32 or F = 1.8(C) + 32 Know both Fahrenheit and Celsius scales and normal ranges *** - Solution What is stroke volume? What is normal in adults? - Solution The amount of blood every heart beat pumps into aorta -70 mL Regarding pulse as a vital sign, what does palpating the peripheral pulse do? - Solution It gives rate and rhythm of heartbeat, as well as local data on condition of artery When is the radial pulse usually palpated? - Solution When vital signs are measured What should you use and where should you palpate the radial pulse? - Solution -Use your first three fingers -Palpate it at the flexor aspect of the wrist laterally along radius bone -Push until strongest pulsation is felt If the heart rhythm is REGULAR, how long should you count the number of beats for? - Solution -30 seconds and multiply it by 2 Why is 30 seconds used to take the pulse? - Solution because it is the most accurate and efficient when heart rates are normal or rapid and when rhythms are regular How long should you count the pulse for if the rhythm is IRREGULAR? - Solution 1 full minute -as you begin counting interval, start your count with "zero" for first pulse felt What parts of a pulse should you assess? - Solution -rate -rhythm -force -elasticity What is the normal heart rate range in a resting adult? - Solution 50 to 90 beats per minute

What causes heart rate to vary? - Solution -age (more rapid in infants and children but more moderate during adult and older years) What is tachycardia? - Solution -A more RAPID heart rate, over 90 bpm -occurs with anxiety or with increased exercise to match body's demand for increased metabolism What is bradycardia? - Solution -A SLOWER heart rate, less than 50 bpm -occurs in well trained athlete What is the force of the pulse? - Solution Strength of heart's stroke volume What does a weak, thready pulse reflect? - Solution A decreased stroke volume What does a full, bounding pulse indicate? - Solution Increased stroke volume -Such as with anxiety, exercise and some abnormal conditions What kind of scale is pulse recorded on? What do the numbers indicate? - Solution -A three point scale 3+ full, bounding 2+ normal 1+ weak, thready 0 absent -some agencies use a four point scale "90 bpm 2+" What should someone's breathing be like? How should you monitor respiration? - Solution -relaxed, regular, automatic and silent -instead of telling someone you are monitoring their respiration, maintain your position of counting radial pulse and count respirations How long should you count respirations? - Solution -Count for 30 seconds or 1 minute if you suspect an abnormality What is the ratio of pulse rate to respiratory rate? - Solution 4:

-normally both rise as a response to exercise or anxiety What is blood pressure defined as? - Solution Force of blood pushing against side of its container, vessel wall What is systolic pressure? Diastolic? - Solution Systolic: maximum pressure felt on artery during LEFT VENTRICULAR CONTRACTION, or systole Diastolic: elastic recoil, or resting, pressure that blood exerts constantly between each contraction What is mean arterial pressure, or map? - Solution pressure forcing blood into tissues, averaged over cardiac cycle, measured as diastolic (systolic- diastolic) /3 or diastolic pressure + 1/3 pulse pressure What is average blood pressure in adults? - Solution 120/80 mm Hg -varies with factors such as age (rise into adult years), gender (females lower than males until after menopause then it switches), race (African American usually higher than white) Arm pressure, person may be sitting or lying, with bare arm supported at heart level. What are the steps of taking blood pressure? - Solution 1. Palpate brachial artery; with cuff deflated, center it about 1 inch above brachial artery and wrap it

2. Palpate brachial artery
3. Inflate cuff until artery pulsation obliterated and then 20 to 30 mm Hg beyond
4. Deflate cuff quickly and completely; wait 15 to 30 seconds before reinflating so blood trapped in veins can dissapate What is a blood pressure cuff called? How many sizes are there? - Solution Sphygmomanometer -6 sizes What should the dimensions of the rubber bladder on the BP cuff be? - Solution -About 40% the width of the person's arm and the length should be 80% of this circumference

-Should cover 70% of arm from acromion to olecranon If the BP cuff is too narrow/small, what can the reading be? - Solution Falsely high, up to 50 mm Hg If the BP cuff is wrapped too loose, what can the reading be? - Solution Falsely high If the BP cuff is too large, what can the reading be? - Solution Falsely low When should you not use an automatic BP cuff? - Solution -If systolic < 90 mm Hg, irregular heart rate, shivering, tremors or seizures Orthostatic, or postural vital signs: when should you take serial measurements of pulse and blood pressure? - Solution -you suspect volume depletion -person known to have hypertension or taking antihypertensive medications -person reports fainting or syncope How should you take postural vital signs? - Solution -Have the person rest supine for 2 or 3 minutes and take baseline readings of pulse and BP -Repeat with person sitting -Repeat with person standing -LYING, SITTING, STANDING When should you take orthostatic, or postural vital signs? - Solution -When the position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur -Record BP by using even numbers -Also record person's position, arm used, and cuff size, if different from standard size cuff What is orthostatic hypertension? - Solution B/P systolic drop of 20 mm Hg or increase in pulse by 20 beats/min with quick change to standing How should you weigh an infant? - Solution -on a platform-type balance scale -by age 2 or 3, use upright scale

How should you measure an infant's body length? - Solution Measure it supine by using horizontal measuring board What is the best index of a child's general health? - Solution Physical growth*** Arteries, aorta, away, oxygen - Solution Study measurement of oxygen saturation - Solution What is a normal range of SpO2 for someone with no lung disease and no anemia? - Solution -97 to 99% -greater than 95% with normal hemoglobin At lower oxygen saturations, what is more accurate than the pulse oximeter? - Solution An earlobe probe is more accurate and less affected by peripheral vasoconstriction What is a general survey? - Solution study of whole person What does a general survey cover? - Solution Covers general health state and any obvious physical characteristics You should launch a general survey every moment you first encounter someone or a situation. What are some things you should look for? - Solution What leaves an immediate impression? -Does the person stand promptly as his or her name is called and walk to meet you? Or do they look sick, rising slowly, with shoulders slumped and eyes downcast? -Is a hospital patient conversing with visitors, involved in reading or television, or lying perfectly still? As you proceed through health history, measurements and vital signs, note following points that will add up to general survey. What are the four areas you should be aware of during a GS? - Solution -physical appearance -body structure -mobility -behavior

What does physical appearance consist of? - Solution -age: person appears his or her stated age -sex: sexual development appropriate for gender and age -level of consciousness: person alert and oriented, attends to your questions and responds appropriately -skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesions What does body structure consist of? - Solution -facial features: symmetric with movement -no signs of acute distress present -stature: height appears within normal range for age, genetic heritage -nutrition weight appears within normal range for height and body build; body fat distributed even -symmetry: body parts look equal bilaterally and are in relative proportion posture: person stands comfortably erect as appropriate for age What does mobility consist of? - Solution Gait, normally, base is as wide as shoulder width -Foot placement: accurate, walk smooth, even and well balanced, symmetric in things such as arm swing -Range of motion: note full mobility for each joint, and that movement is deliberate, accurate, smooth ad coordinated -No involuntary movement -Toe and heel walking What does behavior consist of? - Solution -Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation, e.g. serious, thoughtful or smiling and be sure to note expressions while face is at rest and while person is talking -Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly -Is it appropriate for situation? -Speech: articulation clear and understandable What does dress consist of? - Solution -appropriate to climate, looks clean and fits body, and is appropriate to person's culture and age group -for example: Amish women wear clothing from 19th century, Indian women may wear saris

-personal hygiene: person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group When measuring someones weight, what should you use? - Solution -A standardized balance or electronic standing scale -Instruct person to remove his or her shoes and heavy outer clothing before standing on scale -When sequence is necessary, aim for same time of day and same type of clothing worn How should you record weight measured? - Solution In kilograms and pounds What is the conversion for kilograms to pounds? - Solution 1 kg = 2.2 lbs How do you measure height? - Solution -Use wall-mounted device or measuring pole on scale -Align extended headpiece with top of head -person should be shoeless, standing straight, looking straight ahead, with feet and shoulders on hard surface What is body mass index and how do you measure it? - Solution -BMI is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutriton, it assesses body fat distribution as indicator of health risk -Waist to hip ratio -Waist circumference is measured in inches at smallest circumference below rib cage and above iliac crest -Hip circumference measured in inches at largest circumference of buttocks Significant elevation in blood pressure measurements from one day to the next could be attributed to:

1. A decrease in cuff size
2. An increase in cuff size
3. New onset of pain or anxiety
4. Both 1 and 3. - Solution #4, both 1 and 3 The concept of health and healing has evolved in recent years. Which is the best description of health? a. health is the absence of disease

b. health is a dynamic process toward optimal fuctioning c. health depends on an interaction of mind, body, and spirit within the environment d. health is the prevention of disease - Solution c. health depends on an interaction of mind, body and spirit within the environment Which would be included in the database for a new patient admission to a surgical unit? a. all subjective and objective data gathered by a health practitioner from a patient b. all objective data obtained from a patient through inspection, percussion, palpation, and auscultation c. a summary of a patient's record, including laboratory studies d. all subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed - Solution d. all subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed You are reviewing assessment data of a 45 year old male patient and note pain of 8 on a scale of 10, labored breathing, and pale skin color on the electronic health record. This documentation is an example of: a. hypothetical reasoning b. diagnostic reasoning c. data cluster d. signs and symptoms - Solution c. data cluster A patient is in the emergency department with nausea and vomiting. Which would you include in the database? a. a complete health history and full physical examination b. a diet and GI history c. previously identified problems d. start collection of data in conjunction with lifesaving measures - Solution b. a diet and GI history A patient has recently received health insurance and would like to know how often he should visit the provider. How do you respond? a. "it would be most efficient if you visit on an annual basis" b. "there is no recommendation for the frequency of health care visits" c. "your visits may vary, depending on your level of wellness"

d. "your visits will be based on your preference" - Solution c. "your visits may vary, depending on your level of wellness" You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed? a. planning b. assessment c. implementation d. diagnosis - Solution a. planning Which best describes evidence-based nursing practice? a. combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances b. appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient c. completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices - Solution a. combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances What can be determined when the nurse clusters data as part of the critical-thinking process? a. this step identifies problems that may be urgent and require immediate action b. this step involves making assumptions in the data c. the nurse recognizes relevant information among the data d. risk factors can be determined so the nurse knows how to offer health teaching - Solution c. the nurse recognizes relevant information among the data A patient says she is very nervous and nauseated, and she feels like she will vomit. This data would be what type of data? a. objective b. reflective c. subjective d. introspective - Solution c. subjective

The expert nurse differs from the novice nurse by acting without consciously thinking about the actions. This is referred to as: a. deductive reasoning b. intuition c. the nursing process d. focus assessment - Solution b. intuition Which would be considered a risk diagnosis? a. identifying existing levels of wellness b. evaluating previous problems and goals c. identifying potential problems the individual may develop d. focusing on strengths and reflecting an individual's transition to higher levels of wellness - Solution c. identifying potential problems the individual may develop Which would be included in a holistic model of assessment? a. nursing goals for the patient b. anticipated growth and development patterns c. a patient's perception of his or her health status d. the nurse's perception of disease related to the patient - Solution c. a patient's perception of his or her health status The nurse uses health promotion activities with a new patient. What would this focus include? a. the nurse would try to change the patient's perception of disease b. the nurse would search for identification of biomedical model interventions c. the nurse would help to identify negative health acts of the patient d. the nurse would empower the patient to choose a healthier lifestyle - Solution d. the nurse would empower the pt to choose a healthier lifestyle Which is an example of objective data? (measurable) a. pt's history of allergies b. pt's use of medications at home c. last menstrual period 1 month ago d. 2- x 5-cm scar present on the right lower forearm - Solution d. 2- x 5-cm scar present on the right lower forearm During the elevation phase of the nursing process, which action would be included?

a. validating the nursing diagnosis b. establishing priorities related to patient care c. providing information to the patient and family members d. establishing a timeline for planned outcomes - Solution c. providing info to the patient and family members Which statement best describes religion? a. an organized system of beliefs concerning the cause, nature, and purpose of the universe b. belief in a divine or superhuman spirit to be obeyed and worshiped c. affiliation with one of the 1200 recognized religions in the United States - Solution a. an organized system of beliefs concerning the cause, nature, and purpose of the universe The major factor contributing to the need for cultural care nursing is: a. an increasing birth rate b. limited access to health care services c. demographic change d. a decreasing rate of immigration - Solution c. demographic change The term culturally competent implies that the nurse: a. is prepared in nursing b. possesses knowledge of the traditions of diverse peoples c. applies underlying knowledge to providing nursing care d. understands the cultural context of the patient's situation - Solution d. understands the cultural context of the pt's situation you are the triage nurse in the ed and perform the initial intake assessment on a pt who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication? a. maintaining a professional respectful demeanor b. allowing for additional time to complete the process c. providing the patient with a paper and pencil so he or she can write down the answers to the questions that you are going to ask - Solution c. maintaining a professional respectful demeanor... Which culture would describe illness as hot and cold imbalance? a. Asian-American heritage b. African-American heritage

c. Hispanic- American heritage d. American Indian heritage - Solution c. Hispanic-American heritage Of what does the pt believe the amulet is protective? a. the evil eye b. being kidnapped c. exposure to bacterial infections d. an unexpected fall - Solution a. the evil eye Which statement best illustrates the difference between religion and spirituality? a. religion reflects an individual's reaction to life events whereas spirituality is based on whether the individual attends religious services b. religion is characterized by identification of a higher being shaping one's destiny while spirituality reflects an individual's perception of one's life having worth or meaning c. religion is the active interpretation of one's spirituality - Solution b. religion is characterized by identification... the first step to cultural competency by a nurse is to: a. identify the meaning of health to the patient b. understand how a health care delivery system works c. develop a frame of reference to traditional health care practices d. understand your own heritage and its basis in cultural values - Solution d. understand your own heritage and its basis in cultural values which statement is true in regard to pain? a. nurses' attitudes toward their patients' pain are unrelated to their own experiences with pain b. the cultural background of a patient is important in a nurse's assessment of that pt's pain c. a nurse's area of clinical practice is most likely to determine his or her assessment of a pt's pain - Solution b. the cultural background of a pt is important in a nurse's assessment of that pt's pain Which factor is identified as a priority influence on a pt's health status? a. poverty b. lifestyle factors c. legislative action d. occupational status - Solution a. poverty

Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian present? a. "Are you of the Christian faith?" b. "Do you want to see a medicine man?" c. "What cultural or spiritual beliefs are important to you?" - Solution c. cultural beliefs Which statement best describes ethnocentrism? a. the government's description of various cultures b. the tendency to view your own way of life as the most desirable c. a central belief that accepts all cultures as one's own - Solution b. tendency to view your own way of life as the most desirable Which category is appropriate in a cultural assessment? a. family history b. chief complaint c. past medical history d. health-related beliefs - Solution d. health-related beliefs which health belief practice is associated with pt's who are of American Indian heritage? a. wearing bangle bracelets to ward off evil spirits b. eating compatible foods in one's diet c. using swamp root as a traditional home remedy d. believing in a shaman as a traditional healer - Solution b. eating compatible foods in one's diet which statement best reflects the Magicoreligious causation of illness? a. each being is but a part of a larger structure in the world of nature as it relates to health and illness b. causality relationship exists leading to expression of illness c. belief in the struggle between good and evil is reflected in the regulation of health and illness - Solution c. belief in the struggle between good and evil is reflected in the regulation of health and illness What is important about the complete health assessment? - Solution - arrange everything you have learned so far -may have to pause and think of what comes next rather than just gather data

When should you have all the equipment prepared and accessible? - Solution before examination What is the first thing you should note during an assessment? - Solution general appearance What should you look for regarding general appearance? - Solution - appears stated age -level of consciousness -skin color -nutritional status -posture & position comfortable erect -obvious physical deformities -mobility (gait, assistive devices, ROM, able to rise easily from seated position) -facial expression -speech (articulation, pattern, native language) -hearing -personal hygiene What do you measure when doing an assessment? - Solution -height -weight -compute body mass index -vision using Snellen's eye chart Regarding skin, what should you assess? - Solution Examine both hands and inspect nails -for rest of assessment, examine skin that corresponds with regional examination What vital signs do you take during assessment? - Solution -Radial pulse -respirations -BP in arms or lower legs, if indicated -Temp, if indicated What do you look for in the head and face? - Solution -Inspect and palpate scalp, hair and cranium -Inspect face: expression, symmetry, CN VII

-Palpate temporal artery, then temporomandibular joint as person opens and closes mouth -If tender, transilluminate the sinuses What do you do when assessing the eyes? - Solution -test visual fields by confrontation, CN II -test extraocular muscles: corneal light reflex, six cardinal positions of gaze, CN III, IV, VI -inspect external eye structures -inspect conjunctivae, sclerae, corneas, and irides -test pupil size for light and acommodation -darken room -using an opthalmoscope, inspect ocular fundus, including red reflex, disc, vessels, and retinal background What do you do when assessing the ears? - Solution -inspect external ear: position & alignment, skin condition, and auditory meatus -move auricle and push tragus for tenderness -with an otoscope, inspect canal, then tympanic membrane for color, position, landmarks and integrity -test hearing using voice test; tuning fork tests -Weber and Rinne tests What do you do when assessing the nose? - Solution -Inspect external nose for symmetry and lesions -Inspect facial symmetry, CN VII -Test patency of each nostril -With a speculum, inspect the nares, including nasal mucosa, septum and turbinates What do you do when assessing the mouth and throat? - Solution -With a penlight, inspect mouth, including buccal mucosa, teeth and gums, tongue, floor of mouth, palate and uvula -grade tonsils, if present -note mobility of uvula as person phonates "ahh," and test gag reflex, CN IX, and CN X -ask the person to stick out tongue, check CN XII -with a gloved hand, bimanually palpate mouth, if indicated

What do you do for when assessing the neck? - Solution -inspect neck for symmetry, lumps and pulsations -palpate cervical lymph nodes -inspect and palpate carotid pulse, one side at a time; if indicated, listen for carotid bruits -palpate trachea in midline -test ROM and muscle strength against your resistance: head forward and back, head turned to each side, and shoulder shrug, CN XI -palpate thyroid gland from posterior approach -open person's gown to expose all of back for examination of thorax, but leave gown on shoulders and anterior chest What do you look for when assessing the chest? (posterior and lateral) - Solution -inspect the posterior chest: configuration of thoracic cage, skin characteristics, and symmetry of shoulders and muscles -palpate: symmetric expansion; tactile fremitus; lumps or tenderness -palpate length of spinous processes -percuss over all lung fields -percuss costovertebral angle, noting tenderness -auscultate breath sounds, note any adventitious sounds (move around to fact pt, pt remains sitting, for a female breast exam, ask permission to life gown to drape on shoulders, exposing anterior chest, for male lower gown to lap) What do you do when assessing the chest? (anterior) - Solution -inspect respirations and skin characteristics -palpate for tactile fremitus, lumps or tenderness -percuss anterior lung fields -auscultate breath sounds What do you do when assessing the heart and upper extremities? - Solution Heart: ask person to learn forward and exhale briefly; auscultate cardiac base for any murmurs Upper extremities: test ROM and muscle strength of hands, arms, and shoulders; palpate epitrochlear nodes What do you inspect when assessing female breasts? (One) - Solution - inspect for symmetry, mobility, and dimpling as women lifts arms over head, pushes hands on hips, and leans forward -inspect supraclavicular and infraclavicular areas

-help woman to lie supine with head at a flat to 30-degree angle (stand at person's right side, drape gown up across shoulders, and place an extra sheet across lower abdomen) What do you inspect when assessing female breasts? (Two) - Solution - palpate each breast, lifting same side arm up over head (include the tail of Spence and areola) -palpate each nipple for discharge -support person's arm and palpate axilla and regional lymph nodes -teach breast self-examination What do you inspect when assessing male breasts and neck vessels? - Solution Male breasts: inspect and palpate while palpating anterior chest wall, supporting each arm, palpate axilla and regional nodes Neck vessels: inspect each side of neck for a jugular venous pulse, turning person's head slightly to other side; estimate jugular venous pressure, if indicated What do you inspect when assessing the heart? - Solution -inspect precordium for any pulsations or heave (lift) -palpate apical impulse and note location -palpate precordium for any abnormal thrill -auscultate apical rate & rhythm -auscultate w/ the diaphragm of stethoscope to study heart sounds, inching from apex up to base, or vice versa -auscultate heart sounds w/ the bell of stethoscope again inching through all locations -turn person over to left side while again auscultating apex w/ bell (person should be supine, with bed or table flat; arrange drapes to expose abdomen from chest to pubis) What do you inspect when assessing the abdomen? - Solution -inspect for contour, symmetry, skin characteristics, umbilicus, and pulsations -auscultate bowel sounds (everyone should have them, have to listen for 5 minutes in each quadrant before you can say there are none) -auscultate for vascular sounds over aorta and renal arteries -percuss all quadrants, percuss ht of liver span in right midclavicular line, percuss location of spleen, palpate using light palpation in all quadrants, then deep palpation in all quadrants, palpate for liver, spleen, kidneys and aorta, test abdominal reflexes, if indicated

What do you do when assessing the inguinal area, lower extremities, and musculoskeletal? - Solution Inguinal area: palpate each groin for femoral pulse and inguinal nodes; lift drape to expose legs, palpate for temp and pretibial edema Lower extremities: inspect for symmetry, skin characteristics, and hair distribution; palpate pulses, including popliteal, posterior tibial, and dorsalis pedis pulses; separate toes and inspect; test ROM and muscle strength of hips, knees, ankles and feet (ask person to sit up and to dangle legs off bed or table; keep gown on and drape over lap) Musculoskeletal: note muscle strength as person sits up What do you do when assessing neurologic? - Solution -Test sensation in selected areas on face, arms, hands, legs, and feet: superficial pain, light touch, and vibration -Test position sense of finger, one hand -Test stereognosis -Test cerebellar function of the upper extremities using finger-to-nose test or rapid-alternating-movements test -Test cerebellar function of lower extremities by asking person to run each heel down opposite shin -Elicit deep tendon reflexes: biceps, triceps, brachioradialis, patellar, and Achilles -Test the Babinski reflex -Ask person to stand with gown on; stand close to person What do you do when assessing lower extremities and musculoskeletal? - Solution Lower extremities: inspect legs for varicose veins Musculoskeletal: -Ask person to walk across room in his or her regular walk, turn, then walk back toward you, in heel-to-toe fashion -Ask person to walk on toes for a few steps, then to walk on heels for a few steps -Stand close and check for Romberg sign -Ask person to hold edge of bed and to perform a shallow knee bend, one for each leg What do you do when assessing the male genitalia? - Solution -Inspect penis and scrotum -Palpate the scrotal contents; if a mass exists, transilluminate

-Check for inguinal hernia -Teach testicular self-examination What do you do when assessing musculoskeletal? - Solution -Stand behind and check the spine as person touches toes -Stabilize pelvis and test ROM of spine as person hyperextends, rotates, and laterally bends -For male patient, sit on a stool in front of him; person stands What do you do when assessing the male rectum? - Solution -Inspect the perianal area -With a gloved lubricated finger, palpate the rectal walls and prostate gland -Save a stool specimen for an occult blood test What do you do when assessing the female genitalia? - Solution -Inspect perineal and perianal areas -With a vaginal speculum, inspect cervix and vaginal walls -Procure specimens -Perform a bimanual examination; check cervix, uterus, and adnexa -Continue bimanual examining, checking rectum and rectovaginal walls -Save a stool specimen for an occult blood test -Provide tissues for female to wipe perineal area, and help her up to a sitting position What do you do when you're finished with the physical examination? - Solution -Tell patient you are finished with examination and that you will leave room as he or she gets dressed -Return to discuss examination and further plans and to answer any questions -Thank person for his or her time -For hospitalized person, return bed and any room equipment to way you found it -Make sure call light and telephone are within easy reach What is important in regards to documentation and critical thinking? - Solution -Record & document in a timely manner -Note pertinent negative & positive findings -Use short, clear phrases and avoid redundant phrases -Use simple line drawings to identify as well as assist in health teaching

What are components of the health assessment? - Solution -Indicate sources of information Health history -Biographic data -Past health -Family history -Review of systems -Functional assessment -Perception of health Physical Examination -measurement -head to toe examination Assessment -nursing diagnoses Does a pt require a complete head-to-toe physical examination every 24 hours? - Solution NO -pt does require consistent specialized examination at least every 8 hours that focuses on certain parameters -note that some measurements such as daily wt, abdominal girth, or circumference of a limb must be taken carefully -REMEMBER: many assessments must be done frequently throughout course of a shift When performing an assessment, what requires continuous monitoring? (take note of these) - Solution -blood pressure or pulse oximetry reading that is not what you expect, or breath sounds suggesting difficult respiratory effort If there is no protocol in place for a particular assessment situation, how often do you check on a pt? - Solution -YOU must decide for yourself how often you need to check on a pt's status -you must complete them thoroughly, accurately, and rapidly WITHOUT seeming hurried Who does basic reassessment apply to? - Solution -Adults in medical, surgical and in cardiac step-down care areas -each assessment must be specialized to each adult and findings must be integrated into your complete knowledge base regarding pt