Download Final Exam: NURS 190 / NURS190 (Latest Update 2025 / 2026) Physical Assessment | Review Qu and more Exams Nursing in PDF only on Docsity!
Final Exam: NURS 190 / NURS190 (Latest Update 2025 / 2026)
Physical Assessment | Review Questions and Answers | Grade A
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What is subjective data based on? - ANSWERS-Client's statements Can you provide an example of subjective data? - ANSWERS-Client saying 'I have pain in my hip, it radiates to my knees, and it's a 6 out of 10' or "I feel very tired today." What is Objective Data? - ANSWERS-This is measurable and this is actual data collected using the 5 senses, inspection, palpation, percussion, and auscultation, and by overall observing the patient. Example of Objective data - ANSWERS-Vital signs Normo-, hypo-, or hyperactive bowel sounds in the abdomen Wheezing heard in lung sounds. Percussion Tones: Flat - ANSWERS-High pitched tone, very soft and has a short duration Heard over bones like clavicle ribs and sternum Percussion Tones: Dullness - ANSWERS-High pitched tone that is soft and has a short duration Heard in dense organs like liver, spleen, and heart. Also heard in fluid filled areas like ascites. Percussion Tones: Tympany - ANSWERS-Loud, high pitched, drum-like tone of medium duration heard over the abdomen (that is not fluid filled) Percussion Tones: Resonance - ANSWERS-Loud, low-pitched hollow tone of long duration Heard over healthy adult lungs Percussion Tones: Hyperresonance - ANSWERS-Abnormally loud, low pitched tone of longer duration than resonance. Heard in a childrens lungs Fremitus - ANSWERS-Vibratory tremors heard through the chest wall. Can be heard using base of fingers.
Order of abdominal assessment - ANSWERS-Inspection, Auscultation, percussion, superficial (light) palpation, deep palpation Order of assessment for other body systems - ANSWERS-Inspection, palpation, percussion, auscultation Deep palpation - ANSWERS-Use with caution in painful areas Color Variation: Pallor - ANSWERS-Loss of skin color due to absence of oxygenated hemoglobin Color Variation: Absence of color - ANSWERS-loss of melatonin pigment Color Variation: Cyanosis - ANSWERS-Mottled blue color due to inadequate tissue perfusion with oxygenated blood Color Variation: Reddish blue tone - ANSWERS-Ruddy tone due to increase in hemoglobin and stasis of blood in capillaries Color Variation: Erythema - ANSWERS-Redness due to increased visibility of normal oxyhemoglobin Color Variation: Jaundice - ANSWERS-Yellow undertone due to increased bilirubin in blood Color Variation: Uremia - ANSWERS-Pale yellow tone due to retention of urinary chromogens in blood Color Variation: Brown - ANSWERS-Increase in production and deposition of melanin Pressure Ulcers: Stage 1 - ANSWERS-Intact, reddened skin, nonblanchable; no involvement of underlying tissues or structures Pressure Ulcers: Stage 2 - ANSWERS-Partial thickness loss: Involvement of epidermal skin layer and may extend into dermis Pressure Ulcers: Stage 3 - ANSWERS-Full thickness loss: Extends in to subcutanoues tissue Pressure Ulcers: Stage 4 - ANSWERS-Full thickness loss: there is involvement of muscle and bone Abnormal Skin Lesions: Nodule - ANSWERS-Elevated, solid, hard or soft, palpable mass smaller than 2 cm and have circumscribed borders. Example are squamous cell carcinoma, fibroma, intradermal nevi Abnormal Skin Lesions: Vesicle - ANSWERS-Elevated, fluid filled, round or oval shaped, palpable massess with thin/translucent walls and cirumcscribed borders. Smaller than 0.5 cm. Examples are herpes simplex, early chicken pox, and poison ivy Abnormal Skin Lesions: Pustule - ANSWERS-Elevated pus filled vesicle with a circumscribed border. Examples are acne, impetigo, and carbuncles Abnormal Skin Lesions: Cyst - ANSWERS-Elevated, encapsulated, fluid filled, or semi-solid mass orignating in subcutneous tissue or dermis. Usually 1 cm or larger. Example is sebaceous cyst.
S&S: nasal congestion and watery eye May last a few minutes or up to a few hours Headaches: Tension - ANSWERS-Occurs because of sustained contraction of muscles in the head, neck, or upper back Onset: gradual Pain: steady, not throbbing Associated with stress, overwork, position, dental problems, premenustral syndrome, sinus inflammation Hyperthyroidism Signs and symptoms (everything is high) - ANSWERS-Subjective: heat intolerance (high temp), irritabilty/nervousness (high brain activity), insomnia (high brain activity, can't sleep), msucle weakness and fatigue (tired out by no sleep), amenorrhea (no menustration). Objective:Goiter/thyroid gland enlargement, exophthalmos (bulging eyes), tachycardia and cardiac dysrthymias (high heart rate), skin thinning, fine brittle hair, weight loss (high metabolism), increased diaphoresis (sweating) Hypothyroidism: Signs and Symptoms (everything is low) - ANSWERS-Subjective: Fatigue/weakness/feeling tired, depression (low brain activity), heavy menustral periods, difficulty concentrating (low concentration), cold intolerance (low temperature) Objective: Constipation (slow bowels), dry skin and weak nails, cool skin, weight gain (low metabolism)
