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