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49 Cards in this Set

  • Front
  • Back
Which lung has 3 lobes?
The right side
What does the nurse use physical assessment for?
To gather baseline data, supplment, confirm or refute data, confirm and identify nursing diagnoses,to evaluate the physiological outcomes of care.
How do nurses demonstrate accountability for their nursing care?
By evaluating the results of nursing interventions.
What is inspection?
the process of observation.
What are you inspecting each area for?
size, shape, color, symmetry,position and abnormalities.
What aspect of the hand should you use to assess the skin temperature?
Dorsum of hand/fingers.
What is percussion used for?
To determine location, size and density of underlying structures.
What are the five sound produced by percssion?
Tympany, resonance, hyperresonance, dullness, and flatness.
What is auscultation?
Listening to sounds produced by the body.
Which part of the stethoscope is best for low-pitched sounds?
The bell.
What causes the first heart sound?
closing of the mitral valve.
Where is the first heart sound best heard at?
At the fifth intercostal space along the midclavicular line.
What are the 5 skills of conducting a physical assessment?
Inspection, palpation, percussion, auscultation, and olfaction.
What is vital for a successful examination?
Client comfort.
What position would you put you client in to aid in detecting heart murmers?
Lateral recumbent.
When does assessment begin?
When the nurse first meets the client.
What is the first part of the physical examination?
Vital signs.
a weight gain of five pounds a day is indicitive of what?
fluid retention.
What is included in the assessment of the integument?
skin, hair scalp and nails.
What can be revealed in your assessment of the skin?
changes in oxygenation, circulation, nutrition, local tissue damage, and hydration.
Who is most at risk for alterations in their skin?
Neurologically impaired clients, chornically ill, orthopedic clients, clients with deminished metal status, poor tissue oxygenation, low cardiac output,or inadequate nutrition.
What is cyanosis and where are the assessment locations?
Bluish color of the skin. You would assess the nail beds, lips, mouth, skin.
What is yellowing of the skin and what are some causes?
Jaundice and it can be caused byliver disease, destruction of red blood cells.
What can deminish skin turgor?
Edema or dehydration
Surcumscribed elevation of the skin that is filled with serous fluid.
What does the nurse inspect the nail bed for?
Color, dleanlimess, and length, the thickness and shape of the nail plate, the texture of the nail,the angle between the nail and the nailbed.
What causes clubbing of the fingernails?
Chronic lack of oxygen: heart or pulmonary disease.
What is nystagmus?
involuntary ,rhythmical oscillation of the eyes.
Bulging of both eyes can be caused by....
Tears are secreted from what gland?
Low set ears are a sign of which chromosome abnormality?
Down Syndrome
what is ototoxicity?
Injury to auditory nerve resulting from high maintenance doses of antibiotics.
What is tactile femitus?
Vibrations that can be palpated externally during speech.
What is the Allen's test used for?
To assess collateral circulation.
How do you assess capillary refill? What is an appropriate finding?
Blanch nailbed for several seconds. Normal refill should be less than 2 seconds.
How often should BSE be performed in women 20 yrs of age and older?
At what age should women have a routine mammogram?
Age 40
What organ can be palpated in the upper right quadrant?
What is the first technique the nurse employes during a physical exam?
In what order is the abdomen assessed?
Inspection, auscultation, then palpation.
What pattern of comparison is used to auscultate the lungs?
side to side.
What is thermoregulation?
The balance between heat lost and heat produced.
THe transfer of heat from the surface of one object to the surface of another is called...
The transfer of heat from one object to antoher with direct contact....
the transfer of heat away by air movement.
the transfer of heat enery when a liquid is changed to a gas...
When is the body temp. usually lowest? highest?
between 1 and 4 am. 6pm
s/s of heatstroke.
giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances and incontinence.