AND ANSWERS | LATEST 2025/26 UPDATE | RATED
100% CORRECT!!
Subjective Answer - said by pt
objective Answer - observed by nurse
order of techniques Answer - inspection
auscultation
palpation
percussion
order of technique for the abdomen Answer - inspect
auscultate
palpate
percuss
inspection is Answer - always first
palpation Answer - assess texture, moisture, and tenderness
,back of hand (dorsal aspect) to assess temp
deep palpation - 5-8cm
light palpation 1cm
percussion Answer - determine size and shape
action is performed in the wrist
dull
resonant
flat
tympanic
auscultation Answer - listening to sounds produced by the body
diaphragm- high pitched respiratory sounds
bell- low pitched sounds such as heart murmurs
general survey Answer - an overall review or first impression a nurse has of a
pts well being
head-to-toe
visual observation
,appearance Answer - A&O
distress?
body structure/mobility Answer - height and weight WNL?
body parts symmetrical, gait, walking, mobility
behavior Answer - eye contact, speech, clean, groomed?
comprehensive health history Answer - CC,
ROS
fam hx
past hx
social hx
on first encounter with pt
fam hx Answer - across 3 generations
siblings
parents
grandparents
health hx must be completed Answer - each visit
measurements Answer - height
weight
, BMI
Head and chest circumference- birth-36mos
vital signs Answer - temp
pulse
respirations
bp
pain
axillary Answer - armpit
aural Answer - ear
tympanic Answer - across head
respirations Answer - 10-20/min
typically 4:1 ratio of pulse rate to respirations
rapid respirations Answer - tachypnea
slow respirations Answer - bradypnea
pulse Answer - always count 1 full min. if the pulse is irregular
rate and rhythm