Nursing 126 Exam 2
What are the component parts of the physical assessment in order for the thorax and
lungs. - answer Inspection, Palptation, Chest excursion, Tactile fremitus, and
Auscultation of lung sounds.
What are the component parts of the physical assessment in order of the heart and
peripheral vascular system? - answer Inspection, Palptation, and Auscultation
Differentiate between signs of arterial and venous peripheral circulation insufficiency. -
answerVenous Insufficiency: Color-normal or cyanotic; Temperature-normal; Pulse-
normal; Edema-often marked; Skin changes-brown pigmentation around ankles
Arterial Insufficiency: Color-pale (worse with elevation. dusky red when lowered);
Temperature-cool; Pulse-decreased or absent; Edema-absent or mild; Skin changes-
thin, shiny skin (decreased hair growth, thickened nails)
Heart & Vascular Assessment Documentation - answerApical pulse 72 and regular at
5th ICS MCL; S1 > S2 at apex, S2 > S1 at the base, no extra heart sounds; extremities
symmetrical in size, color pink-tan, skin warm; all pulses 2+ and equal bilateral; CRT 2-3
seconds; no edema; negative Homans sign bilateral
What is the normal strength for pulses using the grading scale. - answer0 Absent pulse
1+ Diminished but palpable pulse
2+ Normal pulse
3+ Full pulse, slight increase in strength
4+ Strong, bounding pulse
What are the heart sounds and what do they indicate? - answerThe heart sounds are
S1 (Lub) beginning of systole, closure of AV valves; S2 (Dub) end of systole or start of
diastole, closure of semilunar valves.
What are the component parts of physical assessment of the reproductive system? -
answerInspection- look for asymmetry, edema, inflammation, discharge, masses,
parasites, lesions, defects
Palpation- detection of masses, defects, tenderness, edema
Interview of history
Describe instructions to give the patient regarding doing a self-breast exam. -
answerBSE should be performed by women 20yrs and up; best time is 4-7 days after
menstural cycle.
Stand in front of mirrior and inspest, raise arms, bend over
Lay down and feel breast with oposite hand, use circular motion, cover entire breast
from top to bottom and side to side.
What are the component parts of the physical assessment in order for the thorax and
lungs. - answer Inspection, Palptation, Chest excursion, Tactile fremitus, and
Auscultation of lung sounds.
What are the component parts of the physical assessment in order of the heart and
peripheral vascular system? - answer Inspection, Palptation, and Auscultation
Differentiate between signs of arterial and venous peripheral circulation insufficiency. -
answerVenous Insufficiency: Color-normal or cyanotic; Temperature-normal; Pulse-
normal; Edema-often marked; Skin changes-brown pigmentation around ankles
Arterial Insufficiency: Color-pale (worse with elevation. dusky red when lowered);
Temperature-cool; Pulse-decreased or absent; Edema-absent or mild; Skin changes-
thin, shiny skin (decreased hair growth, thickened nails)
Heart & Vascular Assessment Documentation - answerApical pulse 72 and regular at
5th ICS MCL; S1 > S2 at apex, S2 > S1 at the base, no extra heart sounds; extremities
symmetrical in size, color pink-tan, skin warm; all pulses 2+ and equal bilateral; CRT 2-3
seconds; no edema; negative Homans sign bilateral
What is the normal strength for pulses using the grading scale. - answer0 Absent pulse
1+ Diminished but palpable pulse
2+ Normal pulse
3+ Full pulse, slight increase in strength
4+ Strong, bounding pulse
What are the heart sounds and what do they indicate? - answerThe heart sounds are
S1 (Lub) beginning of systole, closure of AV valves; S2 (Dub) end of systole or start of
diastole, closure of semilunar valves.
What are the component parts of physical assessment of the reproductive system? -
answerInspection- look for asymmetry, edema, inflammation, discharge, masses,
parasites, lesions, defects
Palpation- detection of masses, defects, tenderness, edema
Interview of history
Describe instructions to give the patient regarding doing a self-breast exam. -
answerBSE should be performed by women 20yrs and up; best time is 4-7 days after
menstural cycle.
Stand in front of mirrior and inspest, raise arms, bend over
Lay down and feel breast with oposite hand, use circular motion, cover entire breast
from top to bottom and side to side.
