INSTRUCTIONS: To complete this exercise, circle the letter of the response that best answers the question or completes the statement or write the answer in the space provided. After you have completed the all of the exercises, turn to “Solutions to Exercises” at the end of this lesson and check your answers. If you have responded to any of the exercises incorrectly, reread the material referenced after the answer.
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 | Column II |
| 9. ___ Vertigo
10. ___ Epistaxis 11. ___ Accommodation 12. ___ Tinnitus |
a. Ringing in the ears
b. Dizziness c. Nose bleeds d. Ability of the eye lens to adjust to objects at varying distances |
______________________________________________.
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.
Check Your Answers
SOLUTIONS TO EXERCISE, LESSON 6
1. An organized systematic process of collecting objective data based upon a health history and head-to-toe or general systems examination. (para 6-2a)
2. first (para 6-2b)
3. Nursing care plan (para 6-2b)
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. (paras 6-3b(1)–(4))
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. (paras 6-4a–f)
6. Inspection, palpation, auscultation, percussion. (paras 6-5a–d)
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 (paras 6-6a–h
8. The following is correct:
The patient’s strengths and weaknesses.
Health risks such as hereditary and environmental factors.
Potential and existing health problems. (para 6-7a)
9. b (para 6-7c(3))
10 c (para 6-7c(4))
11. d (para 6-7d(2))
12 e (para 6-7c(3))
13. One dull, low-pitched sound. (para 6-7f(3))
14. Shorter; higher pitch. (para 6-7f(3))
15. Abdominal auscultation. (para 6-7g(2))
16. A small object from a flat surface. (para 6-7i(6))
17. Organized; systems. (para 6-8a)
18. 24. (para 6-8a)