Deck 11: Physical Assessment

Question 1

Discuss the possible clinical findings of a client with hyperactive versus hypoactive bowel.

Answer 1

Hyperactive bowel sounds: due to blood in bowel,diarrhea or to partial bowel obstruction (sounds become high-pitched and tinkling or come in "rushes," followed by silence as obstruction progresses).Hypoactive bowel sounds: absent bowel sounds may be due to complete bowel obstruction or systemic illness.Bowel sounds hypoactive,quiet,and infrequent may be due to paralytic ileus or no obvious cause.

Question 2

Explain briefly how to test a client's ability to either flex or extend his or herarms or legs.

Answer 2

Assess flexion and extension strength in extremities (four possible answers).
a.Stand in front of client,place your hand in front of client,and ask client to push your hand away.
b.Place your hand on client's forearm and ask client to pull his or her arm upward.
c.Position client's leg with knee flexed and foot resting on bed;as you try to extend leg,ask client to keep his or her foot down.
d.Place one hand on client's knee and one hand on client's ankle;ask client to straighten his or her leg as you apply resistant force to knee and ankle.

Question 3

When apical pulse is greater than carotid pulse,it indicates

Answer 3

Pulse deficit.

Question 4

While conducting a cardiac assessment,what position is best for hearing the S₁ and S₂ heart sounds?

Question 5

You are to assess a client's reflexes.Identify the four major reflexes.
a.
b.
c.
d.

Question 6

The sequence for abdominal examination techniques is

A)Palpation,percussion,inspection,auscultation.
B)Inspection,auscultation,palpation,percussion.
C)Percussion,auscultation,palpation,inspection.
D)Auscultation,palpation,percussion,inspection.

Question 7

To assess the first cranial nerve,the examiner uses

A)Aromatic substances.
B)A penlight.
C)An ophthalmoscope.
D)A tuning fork.

Question 8

When completing an obstetrical assessment,Leopold's maneuver is often completed.List the rationale for each maneuver.
a.First maneuver
b.Second maneuver
c.Third maneuver
d.Fourth maneuver

Question 9

What does decerebrate posturing tell you about the client's condition?

Question 10

A normal plantar response is characterized by

A)Toes going up.
B)Toes going down.
C)Client laughing.
D)Toes spreading.

Question 11

The tricuspid valve sound is best heard at the

A)Second intercostal space,left sternal border.
B)Second intercostal space at the sternal border.
C)Midclavicular line,fifth intercostal space.
D)Left,fifth intercostal space at sternal border.

Question 12

Describe the significance of S₃ and S₄ heart sounds and how they are most easily heard.

Question 13

When a client experiences decorticate or abnormal flexor posturing,in what position do you expect to find his or her extremities?

Question 14

Which of the following statements is true regarding changes in assessment findings for the geriatric client?

A)Ciliary activities increase,leading to increased mucous production.
B)Increased ability to retain water.
C)Decreased vascular fragility.
D)Decreased number and size of sweat glands.

Question 15

Bronchovesicular breath sounds are heard normally over the

A)Lung base.
B)Trachea above the sternal notch.
C)Mainstem bronchi below the clavicle.
D)Entire lung parenchyma.

Question 16

When checking the client's pupils,list four aspects that are observed.
a.
b.
c.
d.

Question 17

The normal sequence of the physical examination should be

A)Palpation,percussion,inspection,auscultation.
B)Inspection,palpation,percussion,auscultation.
C)Percussion,auscultation,palpation,inspection.
D)Auscultation,palpation,percussion,inspection.

Question 18

The most reliable index for determining cerebral function is the .