11-2 Exercises for Lesson 11

1. Physical assessment is ______

2. The physical assessment is the ______  step in the nursing process.

3. The physical assessment provides the foundation for the ______ in which your observations play an integral part in the assessment, intervention, and evaluation phases.

4. Two purposes for a physical assessment are:

a. ______

b. ______

5. When preparing a patient for a physical assessment, six nursing considerations are:

a. ______

b.______

c. ______

d. ______

e. ______

f. _______

6. The four basic techniques used in performing a physical assessment are:

a. ______

b. ______

c. ______

d. ______

7. Four specific areas of a general appearance and behavior assessment are:

a. ______

b. ______

c. ______

d. ______

8. One of the components of a systemic or head-to-toe physical assessment is the

health history, which should clearly identify

a. ______

b. ______

c. ______

SPECIAL INSTRUCTIONS FOR EXERCISES 9 THROUGH 12. Match the term in Column I with its definition in Column II.

Column I

9. ___ Vertigo

10. ___ Epistaxis

11. ___ Accommodation

12. ___ Tinnitus

Column II

a. Ringing in the ears

b. Dizziness

c. Nose bleeds

d. Ability of the eye lens to adjust to objects

at varying distances

13. Several heart sounds can be heard by auscultation. S1, the first heart sound, is heard as ______

14. The second heart sound, S2, is ______ and has a ______  than S1.

15. ______  should be performed before percussion and palpation because intestinal activity and bowel sounds may be altered by the motion of percussion and palpation.

16. To assess fine motor coordination, you should have the patient pick up __________

17. Documentation of the physical assessment should be done in an ______  fashion according to ______ .

18. The nursing history and assessment should be completed within _______ hours of admission.


Answers to Exercises for Lesson 11

1. An organized systematic process of collecting objective data based upon a health history and head-to-toe or general systems examination.

2. first

3. Nursing care plan

4. Any two of the following are correct:

To obtain baseline physical and mental data on the patient.

To supplement, confirm, or question data obtained in the nursing history.

To obtain data that will help the nurse establish nursing diagnoses and plan patient care.

To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems.

5. Establish a positive nurse/patient rapport.

Explain the purpose for the physical assessment.

Obtain an informed, verbal consent for the assessment.

Ensure confidentiality of all data.

Provide privacy from unnecessary exposure.

Communicate special instructions to the patient.

6. Inspection, palpation, auscultation, percussion.

7. Any four of the following are correct.

Demographic data

Body build

Posture and gait

Hygiene and grooming

Dress

Body and breath odors

Attitude

Affect/mood

Speech

8. The following is correct:

The patient's strengths and weaknesses.

Health risks such as hereditary and environmental factors.

Potential and existing health problems.

9. b

10 c

11. d

12 e

13. One dull, low-pitched sound.

14. Shorter; higher pitch.

15. Abdominal auscultation.

16. A small object from a flat surface

17. Organized; systems.

18. 24.

End of Lesson 6