HEALTH ASSESSMENT BASICS
This is the correct sequence for a general physical exam.
What is inspection, palpation, percussion, and auscultation?
This test is considered normal when the client hears the tuning fork equally in both ears with no lateralization.”
What is the Weber test?
Alert and oriented ×3 refers to awareness of these three things.
What is person, place, and time?
The closing of these valves produces the S1 heart sound.
What are the mitral and tricuspid valves?
This bluish discoloration of the lips and nail beds indicates severe hypoxia.”
What is cyanosis?”
This part of the hand is best used to assess skin temperature.
What is the dorsal surface?
This age-related change refers to difficulty seeing close objects.
What is presbyopia?
A positive heel-to-shin test indicates dysfunction in this neurological area.
What is the cerebellum?
This visible neck pulsation reflects the hemodynamics of the right atrium.
What is the jugular venous pulse (JVP)?
These high-pitched musical lung sounds occur when air passes through narrowed airways.
What is wheezing?
This percussion sound is normally heard over healthy lung tissue.
What is resonance?
Tenderness over the maxillary sinuses during palpation suggests this condition.
What is sinus infection or sinusitis?
This reflex causes the toes to fan outward when the sole of the foot is stroked.
What is the Babinski reflex?
This extra heart sound is heard in early diastole and is often associated with heart failure.
What is an S3 sound?
These soft, low-pitched sounds are normally heard over most of the peripheral lung fields.
What are vesicular breath sounds?
This is the correct assessment sequence for the abdomen.
What is inspect, auscultate, percuss, and palpate?
This type of hearing loss results from damage to the inner ear or nerve pathways.
What is sensorineural hearing loss?
The ability to recognize letters or numbers traced on the skin during sensory testing refers to this neurological function.
What is graphesthesia?
During a respiratory assessment, a client reports waking up suddenly at night feeling “like I’m drowning.” This finding suggests:
Paroxysmal nocturnal dyspnea
This abnormal lung percussion gives a booming resonance and occurs in hyperinflated lungs.
What is hyperresonance?
This step of the nursing process is always performed FIRST when a patient reports severe pain.
What is assessment?
Smooth, coordinated eye movement in all six directions demonstrates integrity of these three cranial nerves.
What are cranial nerves III, IV, and VI?
The arms and legs are stiff and straight (extended), the toes point down (flexion plantar), and the wrists twist outward (pronated).
What is decerebrate posturing?
This is the order of auscultation points during a cardiac exam.
What are aortic, pulmonic, Erb’s point, tricuspid, and mitral?
This condition may cause decreased expansion on one side due to obstruction, collapse, or surgical pain.
What is atelectasis?