General Survey
Name two items that may be documented on in the general survey section of the nurse's note.
Patient's general appearance, demeanor, body stature and apparent nutritional status.
A normal finding in the ear canal using the otoscope which also serves as a protective function.
Cerumen
This is the normal numerical reflection of transverse chest diameter to anterior-posterior diameter.
2:1
These two valves close when the heart contracts.
Mitral and tricuspid valves
This condition occurs when fluid builds up between the layers of the peritoneal cavity.
Ascites
This step is taken before the general survey and before any examinations.
Hand washing/hand hygiene
This chart is used to assess visual acuity by having the patient read letters at various sizes from a distance.
Snellen chart
The sound associated with this condition is best heard with the bell of the stethoscope over the carotids.
Bruit
This area is located at the fifth intercostal space, mid-clavicular line and where some heart sounds may be heard loudest.
Point of maximal impulse (PMI) at the base of the heart
The nurse listens for how long at any abdominal quadrant if bowel sounds appear absent?
5 minutes
When initiating any physical exam, this is the first of four approaches the nurse will take.
Inspection
An otoscope, with a probe cover, can accurately help inspect the ear canal and what other area on the HEENT exam?
Nose
This gland is located on the floor of the mouth on either side of the frenulum.
Which condition is caused by back up of lymphatic fluid that results in unilateral swelling?
Lymphedema
Percussion during the abdominal exam begins where?
Right lower quadrant
This type of data that comes from the patient or secondary sources as opposed to observed assessment findings.
Subjective data
To assess the internal ear canal of a patient of child age, the pinna is pulled in this direction.
Down
Where does the nurse stand to accurately perform a thyroid assessment?
Posterior to the patient
The wounds of this peripheral disease are often found below the ankle, are dry, red and appear punched out.
Peripheral arterial disease
If an area of the abdomen is tender, when should the nurse assess that area?
Last
This step of the physical abdominal exam happens before touching the abdomen.
Auscultation
This is the expected response of the pupils when testing visual accommodation?
Constriction
Which percussion sound is heard over solid organs or areas of fluid?
This finding indicates risk for right sided heart failure and is clearly visible on inspection of the neck.
Juglar vein distention
Name two aspects of aging that can put the elderly patient at high risk for nutritional deficits?
Difficulty chewing or swallowing
Decreased appetite
Decrease function to feed self
Decrease senses of taste and smell
Slower peristalsis