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NUR131 Physical Assessment

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    Physical Assessment
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  • The four steps of the physical assessment process are:
    Auscultate, Inspect, Palpate, Percuss
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  • What area of the body does not follow the usual four step order?
    The Abdomen
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  • What order should you perform the four steps of assessment on the abdomen?
    Inspect, Auscultate, Percuss, then Palate
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  • Palpation uses the sense of touch. Name three things you are assessing when using palpation
    Firmness, contour, shape, tenderness and consistency. Skin texture and edema. Checking for lumps, temperature, moisture, turgor
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  • When checking skin temperature it is best to use what part of the hand?
    the back of your hand
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  • When obtaining height and weight of a patient, what is the name of the measurement we use to determine if a person is overweight, underweight or normal?
    BMI
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  • If the patient is in the Sims position, how are they positioned?
    Laying on either side with both knees flexed and the top knee more acutely flexed
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  • Percussion is used to?
    Check the location, size, shape and density of tissue.
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  • When percussing over the lung field you should hear?
    Resonance (in normal air filled lungs)
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  • Name three things that would make you question if a mole was malignant
    Asymmetry, Irregular border. Color variation, diameter larger than a pencil eraser, pt reports a recent change in it.
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  • When inspecting the hair name three things you look for-
    Color, texture, distribution, pigmentation
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  • What is pallor?
    paleness
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  • What is jaundice?
    yellowing of the skin and sclera
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  • What is cyanosis?
    bluish or grayish coloring of the skin/nailbeds/lips due to lack of oxygenation
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  • Where is the best area to check for cyanosis, jaundice or pallor in a dark skinned individual?
    Eyes, oral mucous membranes, palms, soles and lips
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  • The angle between the nail and its base should be about __?__ degrees
    160
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