Health Assessment and Physical
Examination
List the five nursing purposes for performing a physical assessment. (5) - ANSWER
a. Gather baseline data about the patient's health status
b. Support or refute subjective data obtained in the nursing history
c. Confirm and identify nursing diagnoses
d. Make clinical judgments about a patient's changing health status and
management
e. Evaluate the outcomes of care
List the principles related to the nurse performing daily physical examinations. (4) -
ANSWER a. A head-to-toe assessment is required daily
b. Reassessment is performed when the patient's condition changes as it improves
or worsens
c. The environment, equipment, and patient are properly prepared
d. Safety for confused patients should be a priority
Proper preparation for examination should include: (5) - ANSWER a. Infection
control
b. Environment
c. Equipment
d. Physical preparation of the patient
e. Psychological preparation of the patient
List seven variations in the nurse's individual style that are appropriate when
examining children. (7) - ANSWER a. Gather all or part of the histories of infants
and children from parents
b. Perform the examination in a nonthreatening are and provide time for play
c. Offer support to the parents during the examination and do not pass judgment
d. Call children by their first names and address their parents as Mr. and Mrs.
e. Use open-ended questions to allow parents to share more information
f. Treat adolescents as adults
g. Provide confidentiality for adolescents; speak alone with them
List seven variations in the nurse's individual style that are appropriate wen
examining older adults. (7) - ANSWER a. Do not stereotype about aging patients's
level of cognition
b. Be sensitive to sensory or physical limitations (more time)
c. Adequate space is needed
d. use patience, allow for pauses, and observe for details
e. Certain types of information may be stressful to give
f. Perform the examination near bathroom facilities
g. Be alert for signs of increasing fatigue
, Identify the principles to follow to keep an examination well organized. (7) -
ANSWER a. Compare both sides for symmetry
b. If a patient is ill, first assess the systems of the body part most at risk
c. Offer rest periods if the patient becomes fatigued
d. Perform painful procedures near the end of the examination
e. Record assessments in specific terms in the record
f. Use common and accepted medical terms and abbreviations
g. Record quick notes during the examination to avoid delays
Define inspection. - ANSWER Looking, listening, and smelling to distinguish normal
from abnormal findings
Identify the guidelines to achieve the best results during inspection. (6) - ANSWER
a. Adequate lighting is available
b. Use direct light source
c. Inspect each area for size, shape, color, symmetry, position, and abnormality
d. Position and expose body parts as needed, maintaining privacy
e. Check for side-to-side symmetry
f. Validate findings with the patient
Define palpation - ANSWER Using the hands to touch body parts.
Light palpation - ANSWER Pressing inward 1 cm (surperficial)
Deep palpation - ANSWER Depressing the area 4 cm to assess the conditions of
organs.
Define auscultation - ANSWER Listening to the internal sounds the body makes.
Auscultating sounds: Frequency - ANSWER Frequency indicates the number of
sound wave cycles generated per second by a vibrating object
Auscultating sounds: Amplitude - ANSWER Loudness, soft to loud
Auscultating sounds: Quality - ANSWER Sounds of similar frequency and loudness
Auscultating sounds: Duration - ANSWER Length of time that sound vibrations last
List at least 12 specific observations of the patient's general appearance and
behavior that should be reviewed. (12) - ANSWER a. Gender and race
b. Age
c. Signs of distress
d. Body type
e. Posture
f. Gait
g. Body movements
h. Hygiene and grooming
i. Dress
j. Body odor
Examination
List the five nursing purposes for performing a physical assessment. (5) - ANSWER
a. Gather baseline data about the patient's health status
b. Support or refute subjective data obtained in the nursing history
c. Confirm and identify nursing diagnoses
d. Make clinical judgments about a patient's changing health status and
management
e. Evaluate the outcomes of care
List the principles related to the nurse performing daily physical examinations. (4) -
ANSWER a. A head-to-toe assessment is required daily
b. Reassessment is performed when the patient's condition changes as it improves
or worsens
c. The environment, equipment, and patient are properly prepared
d. Safety for confused patients should be a priority
Proper preparation for examination should include: (5) - ANSWER a. Infection
control
b. Environment
c. Equipment
d. Physical preparation of the patient
e. Psychological preparation of the patient
List seven variations in the nurse's individual style that are appropriate when
examining children. (7) - ANSWER a. Gather all or part of the histories of infants
and children from parents
b. Perform the examination in a nonthreatening are and provide time for play
c. Offer support to the parents during the examination and do not pass judgment
d. Call children by their first names and address their parents as Mr. and Mrs.
e. Use open-ended questions to allow parents to share more information
f. Treat adolescents as adults
g. Provide confidentiality for adolescents; speak alone with them
List seven variations in the nurse's individual style that are appropriate wen
examining older adults. (7) - ANSWER a. Do not stereotype about aging patients's
level of cognition
b. Be sensitive to sensory or physical limitations (more time)
c. Adequate space is needed
d. use patience, allow for pauses, and observe for details
e. Certain types of information may be stressful to give
f. Perform the examination near bathroom facilities
g. Be alert for signs of increasing fatigue
, Identify the principles to follow to keep an examination well organized. (7) -
ANSWER a. Compare both sides for symmetry
b. If a patient is ill, first assess the systems of the body part most at risk
c. Offer rest periods if the patient becomes fatigued
d. Perform painful procedures near the end of the examination
e. Record assessments in specific terms in the record
f. Use common and accepted medical terms and abbreviations
g. Record quick notes during the examination to avoid delays
Define inspection. - ANSWER Looking, listening, and smelling to distinguish normal
from abnormal findings
Identify the guidelines to achieve the best results during inspection. (6) - ANSWER
a. Adequate lighting is available
b. Use direct light source
c. Inspect each area for size, shape, color, symmetry, position, and abnormality
d. Position and expose body parts as needed, maintaining privacy
e. Check for side-to-side symmetry
f. Validate findings with the patient
Define palpation - ANSWER Using the hands to touch body parts.
Light palpation - ANSWER Pressing inward 1 cm (surperficial)
Deep palpation - ANSWER Depressing the area 4 cm to assess the conditions of
organs.
Define auscultation - ANSWER Listening to the internal sounds the body makes.
Auscultating sounds: Frequency - ANSWER Frequency indicates the number of
sound wave cycles generated per second by a vibrating object
Auscultating sounds: Amplitude - ANSWER Loudness, soft to loud
Auscultating sounds: Quality - ANSWER Sounds of similar frequency and loudness
Auscultating sounds: Duration - ANSWER Length of time that sound vibrations last
List at least 12 specific observations of the patient's general appearance and
behavior that should be reviewed. (12) - ANSWER a. Gender and race
b. Age
c. Signs of distress
d. Body type
e. Posture
f. Gait
g. Body movements
h. Hygiene and grooming
i. Dress
j. Body odor
