NURS 190 PHYSICAL ASSESSMENT FINAL EXAM
Four basic techniques for physical assessment? - (answer)inspect, auscultate, percuss, palpate
The first technique that a nurse should use on a initial focus assessment? - (answer)inspection
Assessment used by the nurse to elicit crepitus on a patient who sustained chest injury, example would
be... - (answer)palpation
what assessment technique does the nurse uses when listening to the HEART SOUNDS and LUNG
SOUNDS? - (answer)auscultation
what technique will the nurse will use elicit to diaphragmatic excursion - (answer)percussion
Which percussion technique is used to assess full or distended bladder - (answer)indirect percussion
assessment for sinus - (answer)direct percussion
For CVAT (costovertebral angle tenderness) - (answer)blunt percussion
-doppler: - (answer)assess pulses when they cant be palpated
-woodlamp: - (answer)used to assess fungal infection on the skin
stadiometer: - (answer)used to measure height of patient
goniometer - (answer)used to measure the degree of joint flexion and extension
transilluminator - (answer)instrument used to detect air, blood, fluid, or a mass in the body cavity
Skin fold - (answer)measure thickness of sub-q tissue
grading pulses - (answer)0+= No pulse
1+ = weak thready
2+ = Normal
3+ = brisk
4+ = bounding
Locations of pulses:
popliteal
,brachial
radial
ulnar
femoral - (answer)popliteal : behind the knee medially
brachial: antecubital (brachial pulses)
radial: thumb (radial pulses)
ulnar: small finger (ulnar pulses)
femoral: inguinal area
what part of the hand do you assess skin temperature? - (answer)dorsal part
what part of the hand do you uses to percuss "INDIRECT PERCUSSION" - (answer)middle finger
Annular vs. Target lesions - (answer)-Annular: only has one circle
-Target: has concentric circles, sometimes has a dot in the center (bullseye)
target lesion is usually seen in patient with? - (answer)lyme dx. (tick bite)
annular lesion example is - (answer)ring worm
Different types of lesions:
annular
target
discrete
confluent
, grouped
wheal - (answer)-Annular: one circle-
Target: lesions with concentric circles of color
Discrete: separated
Confluent: run together-Linear: lesions that form a line
Grouped: lesions that are together
Wheal: caused by insect bite or hive (reddened and irregular border)
Difference between vesicle & bullae - (answer)-Vesicle: elevated, round or oval shape, palpable mass
with thin translucent wall, filled with clear fluid >0.5 cm
Bullae: type of vesicle but LARGER <0.5 cm (burn blister)
bullae is bigger than vesicle
When a vesicle or a bullae becomes infected what does it become - (answer)pustule (lesion is filled with
pus)
Grading of skin edema: push hard around bony prominences with 3 finger pads - (answer)0=no edema
1+=2mm
2+=4mm
3+=6mm
Four basic techniques for physical assessment? - (answer)inspect, auscultate, percuss, palpate
The first technique that a nurse should use on a initial focus assessment? - (answer)inspection
Assessment used by the nurse to elicit crepitus on a patient who sustained chest injury, example would
be... - (answer)palpation
what assessment technique does the nurse uses when listening to the HEART SOUNDS and LUNG
SOUNDS? - (answer)auscultation
what technique will the nurse will use elicit to diaphragmatic excursion - (answer)percussion
Which percussion technique is used to assess full or distended bladder - (answer)indirect percussion
assessment for sinus - (answer)direct percussion
For CVAT (costovertebral angle tenderness) - (answer)blunt percussion
-doppler: - (answer)assess pulses when they cant be palpated
-woodlamp: - (answer)used to assess fungal infection on the skin
stadiometer: - (answer)used to measure height of patient
goniometer - (answer)used to measure the degree of joint flexion and extension
transilluminator - (answer)instrument used to detect air, blood, fluid, or a mass in the body cavity
Skin fold - (answer)measure thickness of sub-q tissue
grading pulses - (answer)0+= No pulse
1+ = weak thready
2+ = Normal
3+ = brisk
4+ = bounding
Locations of pulses:
popliteal
,brachial
radial
ulnar
femoral - (answer)popliteal : behind the knee medially
brachial: antecubital (brachial pulses)
radial: thumb (radial pulses)
ulnar: small finger (ulnar pulses)
femoral: inguinal area
what part of the hand do you assess skin temperature? - (answer)dorsal part
what part of the hand do you uses to percuss "INDIRECT PERCUSSION" - (answer)middle finger
Annular vs. Target lesions - (answer)-Annular: only has one circle
-Target: has concentric circles, sometimes has a dot in the center (bullseye)
target lesion is usually seen in patient with? - (answer)lyme dx. (tick bite)
annular lesion example is - (answer)ring worm
Different types of lesions:
annular
target
discrete
confluent
, grouped
wheal - (answer)-Annular: one circle-
Target: lesions with concentric circles of color
Discrete: separated
Confluent: run together-Linear: lesions that form a line
Grouped: lesions that are together
Wheal: caused by insect bite or hive (reddened and irregular border)
Difference between vesicle & bullae - (answer)-Vesicle: elevated, round or oval shape, palpable mass
with thin translucent wall, filled with clear fluid >0.5 cm
Bullae: type of vesicle but LARGER <0.5 cm (burn blister)
bullae is bigger than vesicle
When a vesicle or a bullae becomes infected what does it become - (answer)pustule (lesion is filled with
pus)
Grading of skin edema: push hard around bony prominences with 3 finger pads - (answer)0=no edema
1+=2mm
2+=4mm
3+=6mm
