2024-2025 NURS190 Physical Assessment Final Exam (30 Solved Assessments)

Name: 2024-2025 NURS190 Physical Assessment Final Exam (30 Solved Assessments)
Brand: Academic Documents Platform
Price: 4.99 USD
Availability: InStock
Author: Isabella White

2024-2025 NURS190 Physical Assessment Final Exam lets you test yourself with actual exam-style questions.

Isabella White

Contributor

4.5

118

about 2 months ago

Preview (13 of 41)

NURS 190 Physical
Assessment Final latest
2024/2025 EXAM
Inspection technique (3):
● FIRST technique with general survey
● General survey:
○ Observing mobility / gait, physical appearance, general wellness/health, mood &
behavior (facial expressions, interactions), mental status (observing patient’s
body language and response when asking questions)
● Do it the SAME WAY every time → less likely to forget something
● Do not rush it, especially with anxious patients
○ Make sure the patient is comfortable
○ Temperature in the room is suitable for the patient
● Make sure that you have everything that you need → so that the patient has
confidence in you
● Know normal vs abnormal when surveying appearance & symmetry
○ Compare ANYTHING that has a pair
○ Eyes- level, equal, is there eyelid drooping?
○ Smile- is there a droop?
○ Always compare the two sides to ensure that there is no abnormality
between the two sides
● Listen for natural sounds
○ Abnormal sounds: wheezing, labored breathing, crepitus during ROM
● Detect abnormal odors:
○ CDIFF, alcohol on a patient, acetone / sugary breath
● Try not to assume anything ! → use critical thinking!
○ Ex: someone with low blood sugar or issues with hypoxia can appear intoxicated
● Know your normal values:
○ Blood pressure, HR, RR, O2 sats, temperature
○ For each age levels
■ Infants: must faster RR than elderly
Percussion technique (3)
● Types:
○ Direct percussion- tapping body with fingertips of dominant hand

■ For a small infant → direct percussion on the chest
■ Adult → on the sinuses on the face
○ Blunt percussion- place palm of nondominant hand flat against the surface and
strike it with closed-fist dominant hand
■ Used to assess the kidneys → assessing for pain / tenderness

(UTI)
○ Indirect percussion- most commonly used
■ Plexor = hammer or tapping finger
■ Pleximeter = device or surface that accepts the tap
● Sounds:
○ Intensity of amplitude: softness or loudness
○ Pitch or frequency: high or low (vibrations per second)
○ Duration: length of time
○ Quality: recognizable overtones or drumlike sounds
● Tympany- sound heard over stomach or intestines
○ Loud, high-pitched, drum-like tone
● Resonance- normal sound heard over lungs
○ Loud, low-pitched, hollow tone
● Hyperresonance- air trapped in lungs
○ Abnormally loud, low tone of longer duration than resonance
■ COPD, trauma or lung collapse
● Dullness- over solid body organs (liver)
○ High-pitched tone, soft and short
● Flatness- over solid tissue, muscle, or bone
○ High-pitched tone, very soft & shorter than dullness
■ Ex: ribs
Skin assessment (5)
● Life span considerations:
○ Infants and children
■ Newborn skin → covered with vernix caseosa
■ Infants have thin, soft, skin and free of hair
■ Milia and stork bites- common, harmless markings in newborns
■ Mongolian spots- gray, blue or purple spots in sacral and buttocks area
● Fade by age 3
● Try not to confuse it with possibility of abuse → ask the
parent “is this something that has been here since birth?”
■ Poor temperature regulation → do not secrete from glands
○ Pregnant female
■ Skin pigmentation increases → in areolae, nipples, vulva,
perianal area
● Development of melasma and linea nigra down the abdomen
● Resolve itself after pregnancy
■ Hormonal changes→ cause oil and sweat glands to become
hyperactive
● Acne worsens in 1st trimester
■ Hair may fall out during months 1-5
○ Older adult
■ Skin elasticity decreases with aging

Loading page 4...

■ Sebum production decreases → causes dryness
● More prone to skin breakdown
■ Perspiration / sweating decreases
■ Decrease in melanin production → result in gray hair
■ Nails become thicker and more brittle due to decreased amount of
circulation
■ Hair thins because of decrease of hair follicles
■ Liver spots, hyperpigmented freckles, increased amount of skin tags
● Psychosocial considerations:
○ Stressed induced illness:
■ Trichotillomania- hair twisting & pulling
■ Nail biting
■ Visible skin disorders in relation to self-esteem / body image
● Cultural and environmental considerations:
○ Socioeconomic status
■ Not able to go to the doctor because of finances
○ Home environment
■ Are they homeless? → if so, could be more likely to develop skin
cancer due to outside exposure
○ Means of employment
■ If they work outside → important to know
■ Do not assume bad hygiene!! → could be from work
○ Changes in skin color → may be more difficult to detect in patients with
dark skin
○ Dry skin does not necessarily indicate dehydration
○ Skin response to stressors differ from person to person
■ Autoimmune disorders
○ Differences in hair color and texture vary from different cultural groups
○ Prolonged immersion of hands in water can cause paronychia- reddened cuticles
causing infection
○ Table 13.2 (variations) 31:28
● Focused interview- questions related to:
○ Notice any smells / foul odors
○ Changes in color → oxygenation issues or perfusion
○ Sweating → fever, being in the sun too long, excessive sweating
○ Skin:
■ In general
■ Illness or infection
■ Symptoms, pain, behaviors
■ Age
■ External environment
○ Hair:
■ In general
■ Infants and children

Loading page 5...

○ Nails:
■ In general
■ Infants and children
■ Pregnant females
■ Older adult
● Color variations in light and dark skin
○ Pallor- loss of color in skin due to absence of oxygenated hemoglobin
■ Light skin:
● White skin loses rosy tones
● Yellow tone appears more yellow
■ Dark skin:
● Black skin loses its red undertones and appears ash-gray
● Brown skin becomes yellow-tinged
○ Absence of color- loss of pigment
■ Albinism- white/pale blond hair and pink irises
■ Vitiligo- very noticeable as patchy milk-white areas
■ Tinea- appears patchy areas paler than surrounding skin
○ Cyanosis- blue color in skin due to inadequate tissue perfusion
■ Light skin:
● Skin, lips, mucous membranes look blue-tinged; nail beds are blue
■ Dark skin:
● May appear a shade darker
● May be undetectable except for lips, tongue, oral mucous
membranes, nail beds, and conjunctivae
○ Reddish blue tone- ruddy tone due to increased hemoglobin and stasis of blood
■ Light skin: reddish purple hue
■ Dark skin: difficult to detect; normal skin may appear darker in some
patients
○ Erythema- redness of the skin due to increased visibility of normal
oxyhemoglobin
■ Light skin: local inflammation and redness
■ Dark skin: hard to detect; inflammation appear purple or darker than
surrounding skin
○ Jaundice- yellow undertone due to increased bilirubin
■ Generalized; visible in sclera, oral mucosa, hard palate, fingernails, palms
of hands, and soles of the feet
Skin lesions (5)
● Primary lesions:
○ Macule and patch- flat, nonpalpable change in the skin color
■ Macule: Smaller than 1 cm
■ Patch: larger than 1 cm
○ Papule and plaque- elevated, solid palpable masses with a circumscribed

Loading page 6...

border
■ Papule: smaller than 0.5 cm
■ Plaques: groups of papules that form lesions larger 0.5 cm
○ Nodule and tumor- elevated, solid, hard or soft palpable mass extending deeper
into the dermis
■ Nodules: smaller than 2 cm
■ Tumors: may have irregular borders and are larger than 2 cm
○ Vesicle and bulla: elevated, fluid-filled, round or oval-shaped, palpable masses
with thin, translucent walls and circumscribed borders
■ Vesicles: smaller than 0.5 cm
■ Bullae: larger than 0.5 cm
○ Pustule- elevated, pus-filled vesicle or bulla with a circumscribed border
■ Size varies
○ Wheal- an elevated, often reddish area with an irregular border caused by diffuse
fluid in tissues
■ Size varies
○ Cyst- elevated, encapsulated, fluid-filled or semisolid mass originating in
subcutaneous tissue or dermis
■ Usually 1 cm or larger
● Vascular lesions:
○ Ecchymosis- flat, irregular shaped lesion of varying size with no
pulsation; does not blanch with pressure → BRUISE
■ In light skin: bluish, purple mark that changes yellow
■ Brown skin: varies from blue to deep purple
■ Black: darkened area
○ Hemangioma- bright, red raised lesion about 2-10 cm in diameter that does not
blanch with pressure; present at birth or within few months of birth and typically
disappears by age 10
■ Cluster of immature capillaries
○ Cullen sign- periumbilical; could indicate internal bleeding in abdomen
○ Grey turner sign- flank area; could indicate bleeding into peritoneum,
pancreatitis, etc.
○ Hematoma- raised, irregularly shaped lesion similar to ecchymosis except that it
is elevated and looks like swelling
■ Caused by leakage of blood into the skin and subcutaneous tissue
○ Petechiae- flat, red or purple rounded “freckles”; approximately 1-3 mm in
diameter; pinpoint lesions
■ Difficult to detect in dark skin and do not blanch
○ Purpura- flat, reddish-blue, irregularly shaped extensive patches of varying size
○ Port-wine stain- flat, irregular shaped lesion ranging from pale red to deep
purple-red
■ Color deepens with exertion, emotional response, or exposure to extreme
temperatures
■ Present at birth and typically does not fade

Loading page 7...

○ Spider angioma- flat, bright red dot with tiny radiating blood vessels ranging in
size from a pinpoint to 2 cm; blanches with pressure
○ Venous lake- soft, compressible, slightly elevated vascular lesion; color typically
ranges from dark blue to purple
● Infectious lesions:
○ Tinea- fungal infection affecting the body, scalp, or feet
■ Body = tinea corporis
■ Scalp = tinea capitis
■ Feet = tinea pedis (athlete’s foot)
○ Measles (Rubeola)- highly contagious viral disease that causes a rash of red to
purple macules or papules that begins on face, then progresses over the neck,
trunk, arms, and legs
■ Lesions do not blanch
■ Oral mucosa may demonstrate tiny, white spots that look like grains of
salt
○ Varicella (chicken pox)- mild infections disease caused by primary infection with
the varicella zoster virus; small, red, fluid-filled vesicles usually on the trunk from
which the rash progresses to the face, arms, and legs
■ Erupt over several days forming pustules, then crusts
■ Cause intense itching
○ Rubella- highly contagious disease caused by rubella virus; typically begins as
pink, papular rash that is similar to measles but paler
■ Skin lesions begin on the face and then spread over the body
○ Herpes simplex → cold sores
○ Herpes zoster → shingles
■ Clusters of small vesicles that form on the skin along the route of sensory
nerves
○ Impetigo- contagious, bacterial skin infection that usually appears on the skin
around the nose and mouth
■ Lesions may begin as barely perceptible patch of blisters that break,
exposing red, weeping area beneath
■ Tan crust forms over the area
■ Common in children
Nail abnormalities (2)
● Caused by: genetic factors, infectious disease processes, traumatic injuries
● May also provide clues to presence of underlying disease process involving other
body systems
● Spoon nails / koilonychia- can be a sign of anemia, especially iron-deficiency anemia
● Paronychia- soft tissue infection around a fingernail at the cuticle causing inflammation
● Beau lines- occur after illness, injury to the nail, eczema around the nail, during
chemotherapy for cancer

Loading page 8...

● Splinter hemorrhage- can be a manifestation of connective tissue condition such as
lupus or scleroderma; appear as reddish-brown spots in the nail
● Onycholysis- painless separation of the nail from the nail bed; fungal infection causing
the nails to thicken and lift off nail bed
● Clubbing- nails appear convex and wide; angle is greater than 160 degrees
○ Poor oxygenation
Subjective data (3)
Equipment (2)
● Various instruments that help in visualizing, hearing, and measuring data
○ Stethoscope, otoscope, penlight, doppler ultrasound, ophthalmoscope, reflex
hammer, BP machine (table 9.1)
○ Before physical assessment:
■ Gather all equipment !
■ Organize it
■ Place within easy reach for availability
○ Stethoscope- auscultates body sounds such as BP, heart sounds, respirations,
bowel sounds
■ Used on exposed skin!!
■ Components:
● Binaurals- pointed toward face
● Flexible tubing
● End piece
○ Bell- low-pitched sounds (murmurs)
○ Diaphragm- best for high-pitched sounds (lung sounds,
bowel sounds, normal heart sounds)
■ Does not “amplify” sound!! → just isolates them
○ Doppler ultrasonic stethoscope- detect sounds that are difficult to hear with
regular stethoscope
■ Fetal heart sounds, peripheral pulses
■ Use gel → isolates sound waves better
○ Ophthalmoscope- inspects internal eye structures
■ Components:
● Handle & head
● Used to see anterior structure of the eye:
○ Large aperture: dilated pupils
○ Small aperture: constricted pupils
○ Red-free filter: help to see optic disc
○ Grid: if there is any lesions → help to locate size of
lesions
○ Slit

Loading page 9...

○ Otoscope- examines external ear structures
■ Need to make sure you’re using the right size!
● Too large or too small can prevent you from seeing anything
■ Components:
● Handle, light, lens, specula of various sizes
■ Normal appearance of tympanic membrane: clear, pearl colored; no
purulent fluid
○ Wood lamp → used for fungal infection
General survey (2)
● Observing mobility / gait, physical appearance
● General wellness/health
● Mood & behavior (facial expressions, interactions)
● Mental status (observing patient’s body language and response when asking questions)
● Open-ended- intentionally general and encourage the patient to provide additional
information
○ Can be during actual assessment
○ H & P
○ What kind of changes have you noticed that have occurred with your skin?
○ “Tell me more about that…”
● Close-ended- quick and simple, yes or no question
○ Do you have allergies? Are you taking any medication?
Neck assessment (1)
● Inspection of skin
● Testing range of motion
● Observation of carotid arteries and jugular veins
● Palpation of trachea
● Inspection, palpation, and auscultation of thyroid gland
Eye assessment (5)
○ General: “Describe your vision today…”
○ Consider expectations based on:
■ Age
■ Race
■ Environment
■ Health practices
■ Past & current problems / therapies
○ Ask about any infections, surgeries, or injuries
○ Consider patient’s ability to participate → based on any problems
stated that are significant
○ Symptoms, pain and behaviors
○ “When was your last eye exam?” → especially in an older client, diabetic

Loading page 10...

patients
● Lifespan considerations:
○ Infants and children:
■ Did the mother have a vaginal infection?
■ Was the child full term or premature? If premature, how early?
● Could have been over oxygenated in NICU causing visual
problems
○ Pregnant female:
■ Any changes in vision?
■ Reassure mother that it is temporary → will return by 6 months
○ Older adult:
■ Do you have any dryness?
● If the individual OVER USES eye drops → the lacrimal
glands are less likely to continue to produce tears
■ Any problems with night vision? → may affect their daily living
○ Internal environment:
■ Ask whether or not the patient is taking any medications that could affect
vision
■ Is there a family history of eye problems?
● Glaucoma IS inherited
● Cataracts are not genetic
○ External environment:
■ Have they been exposed to any eye irritants?
■ Do they work in an environment that can cause eye irritants?
■ Are they using safety equipment to protect eye?
● Eye assessment (5)
○ Inspection:
■ What does the sclera look like?
● Is it a normal white color?
● Is there jaundice? → can indicate liver problems
■ Looking for redness, drainage
○ Tests:
■ Snellen Tests (distance)- tests for visual acuity
● Tests for cranial nerve II
● Stand 20 feet away and cover one eye
○ Read the smallest line they can possibly read
○ If patient reads half or more of the line wrong →
move up to the next highest level
● First number → 20 feet away from Snellen
○ NEVER CHANGES
● Second number → how far away someone with
normal vision will see what you see
● Ex: 20/40 : you’re standing at 20 feet and seeing what a person

Loading page 11...

with normal vision could see at 40 feet
■ Jaeger / Rosenbaum- near vision
● 12-14 inches away
■ Confrontation test- peripheral vision
● Your eye AND the patient eye are covered on the opposite sides
(same eye when facing each other)
● Something is coming into view → if the patient sees it at
the same time that you do, they have normal vision
■ Cardinal fields of gaze- extraocular muscles
● Cranial nerves 3, 4, 6
● Assessing for any deviation in vision
■ Cover / uncover:
● Normal = no deviation
● Could have a slight deviation → but will not see it until you
cover / uncover the eye
■ PERRLA- pupils are equal, round, and reactive to light and
accommodation
● Pupil size are equal: between 3 and 6
● Reactive to light: constriction when light is shined at them
● Accommodation: eyes converge and pupils constrict when
looking at something close up
■ Consensual constriction - pupil constricts when a light is shone in the eye
○ Palpation:
■ Warmth, tenderness, edema, etc
○ Ophthalmoscope- looking at the internal parts of the eye (pupils)
■ Looking at the fundus, macula
■ Want to see a red reflex → light reflection from the retina
■ Looking for normal blood vessels:
● Are the constricted or enlarged?
■ Are there any lesions?
■ White spots on the macula?
■ Pale conjunctiva → can indicate types of anemia
■ Parts:
● Small aperture- constricted pupils
● Large aperture- pupils that are dilated
● Grid aperture- to detect a presence of any kind of lesion
Eye abnormalities (5)
● Abnormalities of the eyelids:
○ Blepharitis- general inflammation / redness of the eyelids
■ Staphylococcal infection leads to red, scaly, and crusted lids

Loading page 12...

■ The eye burns, itches, and tears
○ Basal cell carcinoma- usually seen on the lower lid and medial canthus
■ Papular appearance
○ Chalazion- firm, nontender nodule on the eyelid arising from infection of the
meibomian gland
■ Not painful unless inflamed
○ Hordeolum- also called a stye
■ Result of staphylococcal infection of hair follicles on the margin of the
lids
■ Affected eye is swollen, red, and painful
○ Entropion- inversion of the eyelid and lashes caused by muscle spasm of the
eyelid
■ Friction from lashes can cause corneal irritation
○ Ectropion- eversion of the lower eyelid caused by muscle weakness exposing the
palpebral conjunctiva
○ Ptosis- drooping of the eyelid
■ Occurs with cranial nerve damage or systemic neuromuscular weakness
○ Periorbital edema- swollen, puffy eyelids
■ Occurs with crying, infection, trauma, systemic problems (kidney failure,
heart failure, allergies)
○ Exophthalmos- abnormal protrusion of one or both eyeballs
■ Usually occurs secondary to Grave’s disease
● Lipids are being deposited in the back of the eye and pushes it out
■ Can also be caused by infectious disease, certain forms of cancer and
other disorders
● Abnormalities of the eye:
○ Conjunctivitis- infection of the conjunctiva usually due to bacteria or virus
■ Pink eye
○ Iritis- serious disorder characterized by redness around the iris and cornea
■ Decreased vision and deep, aching pain
■ Pupil is often irregular
○ Subconjunctival hemorrhage- results from ruptured blood vessel that leads to
blood accumulation in the subconjunctival space
■ Caused by trauma, anticoagulant therapy, hypertension, elevated venous
pressure
○ Pterygium- non-cancerous growth that develops from the conjunctiva and
extends onto the sclera
■ May also extend to the cornea
■ Can cause problems with vision
○ Hyphema- collection of blood in the anterior chamber of the eye that is most
often caused by blunt trauma to the eye
■ Can also be caused by eye surgery, blood vessel abnormalities, medical
problems
○ Acute glaucoma- result of sudden increase in intraocular pressure resulting from

Loading page 13...

10 more pages available. Scroll down to load them.

Preview Mode

100%

Study Now!

XY-Copilot AI

Unlimited Access

Secure Payment

Instant Access

24/7 Support

AI Assistant

Document Details

Subject

Nursing

2024-2025 NURS190 Physical Assessment Final Exam (30 Solved Assessments)

Study Now!

Document Details

Related Documents

The Psychiatric-Mental Health Nurse Practitioner Certification Review Manual (2020)

Test Bank for Medical-Surgical Nursing in Canada, 4th Edition

Test Bank for Community and Public Health Nursing: Evidence for Practice, 3rd Edition (Chapters 1-25)

Test Bank For Understanding Medical-Surgical Nursing, 5th Edition

Test Bank for Lehne's Pharmacology for Nursing Care, 11th Edition (Chapters 1-112)

Test Bank for Pharmacology and the Nursing Process, 10th Edition (Chapters 1-57)

Test Bank for Maternity and Women's Health Care, 13th Edition (Chapters 1-37)

Test Bank for LPN to RN Transitions, 5th Edition (Chapters 1-18)

Test Bank for Foundations for Population Health in Community/Public Health Nursing, 6th Edition (Chapters 1-32)

Test Bank for Fundamentals of Nursing, 10th Edition (Chapters 1-11)