Potter & Perry: Fundamentals of Nursing, 7th Edition
Answer Key to Study Guide Chapter 33: Health Assessment and Physical Examination 1. a. b. c. d. e. 2. a. adequate lighting is available b. position and expose body parts to be viewed c. inspect each area for size, shape, color, symmetry, position, and abnormalities d. compare each area inspected with the same area on the opposite side e. use additional lighting to inspect body cavities f. do not hurry; pay attention to detail 3. involves the use of the hands to touch body parts to make sensitive assessments 4. produces a vibration that travels through the body tissues, which determines the location, size, and density of underlying structures to verify abnormalities assessed 5. involves listening to sounds the body makes with the use of a stethoscope 6. a. infection control b. environment c. equipment d. physical preparation of the client e. psychological preparation of the client 7. a. gather all or part of the histories of infants and children from parents b. perform the examination in a nonthreatening area c. offer support to the parents during the examination d. call children by their first name and address the parents as Mr. and Mrs. e. use open-ended questions to allow parents to share more information f. treat adolescents as adults g. confidentiality for adolescents; speak alone with them 8. a. do not stereotype b. sensory or physical limitations (more time) c. adequate space is needed d. use patience; allow for pauses e. certain types of information may be stressful to give gather baseline data about the client’s health status supplement, confirm, or refute data confirm and identify nursing diagnoses make clinical judgments about a client’s changing health status evaluate the outcomes of care
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
body odor 19. especially in the older adult 27. affect and mood 20. hardened 30. diminished mental status. body movements 16. Answers can be found in Table 33-10. Answers can be found in Box 33-8. perform the exam near bathroom facilities g. dress 18. an affiliate of Elsevier Inc. poor tissue oxygenation. aggressive form of skin cancer 26. thickening of the skin 33. hygiene and grooming 17. fear of the spouse or partner. in the same clothes to allow an objective comparison of subsequent weights 24. eczema b. chronically ill and orthopedic clients. need to weigh clients at the same time of day b. on the same scale c. pediculus humanus capitis (head lice) b. or inadequate nutrition 25. areas of the skin swollen or edematous form a buildup of fluid in the tissues 32. age 11. discolored skin that occurs unevenly. reaction to various medications . gait 15. gender and race 10. be alert for signs of increasing fatigue 9. trauma to skin during care. 28. speech 21. C – have you ever felt the need to cut down on your use? A – have people annoyed you by criticizing your use? G – have you ever felt bad or guilty about your use? E – have you ever used or had a drink first thing in the morning as an eye-opener to steady your nerves or feel normal? 23. 35. physical injury or neglect are signs of possible abuse (evidence of malnutrition or presence of bruising). pediculus humanus corporis (body lice)
Mosby items and derived items © 2009. ruby-red papules 34. neurologically impaired. or parent 22. posture 14. a.Answer Key to Study Guide
f. a. dermatitis 29. a. skin’s elasticity 31. signs of distress 12. 2005 by Mosby. exposure to pressure during immobilization..
. low cardiac output. Inc. caregiver. body type 13.
. sclerae g. impaired near vision in middle-age and older adults. splinter hemorrhages 40. inflammation of the skin at base of the nail 41.Answer Key to Study Guide
c. visual acuity b. enlarged jaws and facial bones 43. choroids. eyebrows c. congenital anomaly or the buildup of cerebrospinal fluid in the ventricles 42.. noninflammatory eye disorder resulting from changes in retinal blood vessels 47. transverse depressions in nails 38. a. eyelids d. a. lacrimal apparatus e. pupils equal. caused by loss of elasticity of the lens 46. position and alignment b. pupils and irises 53. and retinal vessels 60. middle (3 bony ossicles) c. change in the angle between nail and nail base. outer ear canal and tympanic membrane) b. caused by progressive degeneration of the center of the retina 51. conjunctivae f. and semicircular canals) 61. vestibule. softening and flattening and enlargement of the fingertips 37. blurred central vision often occurring suddenly. a thin white ring along the margin of the iris 58. enter the external ear. external (auricle. extraocular movements d. congenital condition in which both eyes do not focus on an object simultaneously 48. Inc. lid margins that turn in 56. round. retina. increased opacity of the lens 49. pediculus pubis (crab lice) 36. an affiliate of Elsevier Inc. a. fovea centralis. a refractive error causing farsightedness 44. a refractive error causing nearsightedness 45. internal eye structures 52. bulging eyes 54. concave curves 39. reactive to light and accommodation 59. optic nerve disc. which indicates and allergy or an infection 57. intraocular structural damage resulting from increased intraocular pressure 50. a. macula. inner ear (cochlea. presence of redness. 2005 by Mosby. visual fields c. external eye structures e. pass through the outer ear canal
Mosby items and derived items © 2009. lid margins that turn out 55.
79. and low-pitched 73. left second intercostal space 84. air movement through smaller airways that is soft. Atria contract to enhance ventricular filling. thick white patches that are often precancerous lesions seen in heavy smokers and alcoholics 68. extra bony growth between the 2 palates 70. a. conduction b. location is not necessarily over the valves
Mosby items and derived items © 2009. an affiliate of Elsevier Inc. tortuous veins that are common in the older adult 69. air moving through trachea which is loud and high-pitched. cochlea receive the vibration e. loudness. lateralization of sound equally in both ears 64. swollen. Inc. sound waves that create vibrations that can be palpated externally 72. Aortic and pulmonic valve closure causes the second heart sound. sensorineural c. with hollow quality 75. between S1 and S2 (systolic) and S2 and S1 (diastolic) c. waves reach the tympanic membrane (vibrate) c. and trachea 71. middle. 76. air moving through larger airways that is blowing. Fourth or fifth intercostal space along the sternum 86.. left midclavicular line 87.
. tip of the sternum 88. or end of the systolic or diastolic phase 89. apex touching the anterior chest wall at approximately the fourth to fifth intercostal space. 78. 81. auscultate all valve areas for placement in the cardiac cycle (timing). characterized by redness and skin sloughing 66. tumor-like growths 67. left third intercostal space 85. mixed 63. and intensity 74. Answers can be found in Table 33-22. sustained swishing or blowing sounds heard at the beginning. carotid arteries. second intercostal space on the right 83. just medial to the left midclavicular line 77. where best heard (location) and radiation. pitch and quality b. 2005 by Mosby. neck muscles.Answer Key to Study Guide
b. comparison of air and bone conduction (AC>BC) 65. medium-pitched. lymph nodes of the head and neck. lies between the sternal body and manubrium and feels the ridge in the sternum approximately 5 cm below the sternal notch 82. Fifth intercostal space just to the left of the sternum. nerve impulses from the cochlea travel to the auditory nerve (8th) and to the cerebral cortex 62. rapid ventricular filling 80. vibrations are transmitted through the middle ear by the bony occicular chain to the oval window of the inner ear d. a. thyroid gland. breezy. jugular veins. Mitral and tricuspid valve closure causes the first heart sound. skin breakdown.
diminished or unequal carotid pulsations 93. Inspect the calves for localized redness. stretch marks 101. and swelling over vein sites. a painless enlargement of one testis and the appearance of a palpable. an exaggeration of the posterior curvature of the thoracic spine 113. an affiliate of Elsevier Inc. creating turbulence 94..
. lateral spinal curvature
Mosby items and derived items © 2009.open ulcers that drain serous material 109. 97. a. which are hyperactive bowel sounds 106. Refer to Table 33-26 for the answers. blood passing through a narrowed section. a test for cervical and vaginal cancer 110. tenderness. localized dilation of a vessel wall 108. hunchback. which is a normal function of the small and large intestine 104. hard lump on the side of the testicle 111. align the head c. level of venous pulsations begin to rise as the patient reaches 45-degree angle d. or fluid in the abdominal cavity 103. to detect colorectal cancer in the early stages and prostatic tumors 112. occurs in clients with peritoneal irritation 107. clinical breast exam every 3 years (20-40) and yearly over the age of 40 d. small.Answer Key to Study Guide
d. sometimes with nipple discharge 100. spreading to the nodes 99. repeat the same measurement on the other side 95. protusion of abdominal organs through the muscle wall 102. movement of contents through the intestines. swayback. Inc. absent sounds that may indicate a lack of peristalsis 105. growling sounds. a. which appear as small. expose the neck. tumor. bilateral lumpy. syphilitic lesions. assess for radiation e. family history: need a yearly exam e. additional testing (increased risks) 98. women aged 20 years and older need to report any breast changes c. 2005 by Mosby. mammogram: age 40 annually (asymptomatic) f. low-pitched murmur best heard with the diaphragm 90. intensity or loudness and record in grading 1-6 f. lean client back into a supine position. 96. swelling by intestinal gas. painful breast. caused by a drop in heart rate and blood pressure 91. an increased lumbar curvature 114. absent pulse wave (blockage) 92. BSE monthly b. semi-Fowler’s position b. use 2 rulers e.
a muscle with little tone 132. pain. temperature. front or ventral surface faces upward 122. 141. metabolic bone disease that causes a decrease in quality and quantity of bone 116. rotation of the joint outward 126. vagus k. measures orientation and cognitive function 134. flexion of toes and foot upward 129. trochlear e. auditory i. a. that the frontal or ventral surfaces face downward 121. movement decreasing angle between 2 adjoining bones 118. a person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate 137.. turning of the body part away from the midline 127. vibration. toward the midline 124. facial h. a person cannot understand written or verbal speech b. and crude and finely localized touch 139. position. pain. glossopharyngeal j. hypoglossal 138. oculomotor d. an objective measurement of consciousness on a numerical scale over time 136. 2-point discrimination 140. position. beyond its normal resting extended position 120. away from the midline 123. light touch. olfactory b. spinal accessory l.Answer Key to Study Guide
115. optic c. a muscle reduced in size that feels soft and boggy 133. abducens g. an affiliate of Elsevier Inc. increased muscle tone 131. turning the body part toward the midline 128. bending of toes and foot downward 130.
Mosby items and derived items © 2009. Muscular activity maintains balance and equilibrium and helps to control posture. measures the precise degree of motion in a particular joint 117. trigeminal f. and restlessness 135. disorientation. vibration. Inc. increasing angle between 2 adjoining bones 119. confusion. a.
. rotation of the joint inward 125. 2005 by Mosby.
143. triceps. 146. the back of the hand is not the best place to test for turgor 144. patellar. 4. smaller than 1 cm 145.Answer Key to Study Guide
a. gluteal. After the ventricles empty. 3. A thorough explanation of the purpose and steps of each assessment lets clients know what to expect and what to do so that they can cooperate.
Mosby items and derived items © 2009. deep tendon reflexes (biceps. normally the skin lifts easily and snaps back immediately to its resting position. 4.
. an affiliate of Elsevier Inc. 3. 3. Use a systematic pattern when comparing the right and left sides. high-velocity airflow through severely narrowed or obstructed airway 147. abdominal) 142. 2005 by Mosby. You need to compare lung sounds in one region on one side of the body with sounds in the same region on the opposite of the body.. cutaneous reflexes (plantar. Achilles) b. 2. Inc. ventricular pressure falls below that in the aorta and pulmonary artery. circumscribed elevation of skin filled with serous fluid. allowing the valves to close and causing the second heart sound.