RASMUSSEN HEALTH ASSESSMENT EXAM 2 BSN: 2017
Skills in order:
Inspection
Palpation
Percussion
Auscultation
Finger tips for assessment
Fine tactile discrimination, swelling, pulsation, presence of lumps
Best spot on hands to determine temp
Dorsa of hands and fingers because skin is thinner
Percussion is to assess?
Location and size of organs
Detectung abnormal masses
Eliciting pain or tendon reflex
Direct percussion
Also called immediate
Strike hand directly contacts body wall
Indirect percussion
Also called mediate
Use both hands, striking hand contacts stationary hand
The nurse is prepared to do a physical assessment on a patient who is end stage
HIV positive. What should the nurse do for self protection?
A. Wash bands and don gloves, gown, and protective dace sheild
B. Din glives and wash hands after examination; no ither protective equipment is
mecessary
C. Wash hands, don glives and wash hand after examination no othe rprotectibve
equipment necessary
C. Dont need gown or mask for HIV positive person, wash hands and gloves needed for
everyone.
The nurse is performing as assessment of the abdominal region. What is the
appropriate sequence for the examination?
A. Palpating, percussion, inspection, auscultation
B. Inspection, palpating, auscultation, percussion
C. Inspection, auscultation, percussion, palpation
C, palpation is last to avoid giving pain to the abdominal region
What position may an ill person with shortness of breathe want to be in?
Someone with fatigue?
Sitting up
Laying down
Gait
Walking and mobility of a person
, Menstrual cycle causes how much of a temp increase?
0.5-1.0
Stroke volume (SV) and average amount?
Volume of blood pumped into aorta each heart beat
70ml
Asses pulse for the following:
Rate
Rhythem
Force
Elasticity
Heart rate normal?
And varies with?
60-100
Age, gender
Tachycardia
Bradycardia
100 plus
60 below
Sinus rhythmia is found with who?
found in children and young adults
Strong pulse means...
Full/strong stroke volume
Pulse force is measured by
Theww point scale
3+ full bounding
2+ normal
1+ weak thready
0 absent
Systolic pressure
Diastolic pressure
Max pressure delt on artery during left ventricular contraction or systole
Elastic recoil or resting pressure blood exerts constabtly between each contraction
Mean arterial pressure (MAP)
Pressure forces blood into tissues
Viscosity
Thickeness of blood
Significant elevation in BP measurements from one day to the next could be
attributed too?
A decrease cuff size
B increeaed cuff size
C new onset of pain or anxiety
D both A and B
Skills in order:
Inspection
Palpation
Percussion
Auscultation
Finger tips for assessment
Fine tactile discrimination, swelling, pulsation, presence of lumps
Best spot on hands to determine temp
Dorsa of hands and fingers because skin is thinner
Percussion is to assess?
Location and size of organs
Detectung abnormal masses
Eliciting pain or tendon reflex
Direct percussion
Also called immediate
Strike hand directly contacts body wall
Indirect percussion
Also called mediate
Use both hands, striking hand contacts stationary hand
The nurse is prepared to do a physical assessment on a patient who is end stage
HIV positive. What should the nurse do for self protection?
A. Wash bands and don gloves, gown, and protective dace sheild
B. Din glives and wash hands after examination; no ither protective equipment is
mecessary
C. Wash hands, don glives and wash hand after examination no othe rprotectibve
equipment necessary
C. Dont need gown or mask for HIV positive person, wash hands and gloves needed for
everyone.
The nurse is performing as assessment of the abdominal region. What is the
appropriate sequence for the examination?
A. Palpating, percussion, inspection, auscultation
B. Inspection, palpating, auscultation, percussion
C. Inspection, auscultation, percussion, palpation
C, palpation is last to avoid giving pain to the abdominal region
What position may an ill person with shortness of breathe want to be in?
Someone with fatigue?
Sitting up
Laying down
Gait
Walking and mobility of a person
, Menstrual cycle causes how much of a temp increase?
0.5-1.0
Stroke volume (SV) and average amount?
Volume of blood pumped into aorta each heart beat
70ml
Asses pulse for the following:
Rate
Rhythem
Force
Elasticity
Heart rate normal?
And varies with?
60-100
Age, gender
Tachycardia
Bradycardia
100 plus
60 below
Sinus rhythmia is found with who?
found in children and young adults
Strong pulse means...
Full/strong stroke volume
Pulse force is measured by
Theww point scale
3+ full bounding
2+ normal
1+ weak thready
0 absent
Systolic pressure
Diastolic pressure
Max pressure delt on artery during left ventricular contraction or systole
Elastic recoil or resting pressure blood exerts constabtly between each contraction
Mean arterial pressure (MAP)
Pressure forces blood into tissues
Viscosity
Thickeness of blood
Significant elevation in BP measurements from one day to the next could be
attributed too?
A decrease cuff size
B increeaed cuff size
C new onset of pain or anxiety
D both A and B
