Potter & Perry: Fundamentals of Nursing, 7th Edition

Answer Key to Study Guide

Chapter 33: Health Assessment and Physical Examination

1.
a. gather baseline data about the client’s health status
b. supplement, confirm, or refute data
c. confirm and identify nursing diagnoses
d. make clinical judgments about a client’s changing health status
e. evaluate the outcomes of care
2.
a. adequate lighting is available
b. position and expose body parts to be viewed
c. inspect each area for size, shape, color, symmetry, position, and
abnormalities
d. compare each area inspected with the same area on the opposite side
e. use additional lighting to inspect body cavities
f. do not hurry; pay attention to detail
3. involves the use of the hands to touch body parts to make sensitive assessments
4. produces a vibration that travels through the body tissues, which determines the
location, size, and density of underlying structures to verify abnormalities
assessed
5. involves listening to sounds the body makes with the use of a stethoscope
6.
a. infection control
b. environment
c. equipment
d. physical preparation of the client
e. psychological preparation of the client
7.
a. gather all or part of the histories of infants and children from parents
b. perform the examination in a nonthreatening area
c. offer support to the parents during the examination
d. call children by their first name and address the parents as Mr. and Mrs.
e. use open-ended questions to allow parents to share more information
f. treat adolescents as adults
g. confidentiality for adolescents; speak alone with them
8.
a. do not stereotype
b. sensory or physical limitations (more time)
c. adequate space is needed
d. use patience; allow for pauses
e. certain types of information may be stressful to give

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Answer Key to Study Guide 33-2

f. perform the exam near bathroom facilities

g. be alert for signs of increasing fatigue
9. gender and race
10. age
11. signs of distress
12. body type
13. posture
14. gait
15. body movements
16. hygiene and grooming
17. dress
18. body odor
19. affect and mood
20. speech
21. physical injury or neglect are signs of possible abuse (evidence of malnutrition or
presence of bruising); fear of the spouse or partner, caregiver, or parent
22.
C – have you ever felt the need to cut down on your use?
A – have people annoyed you by criticizing your use?
G – have you ever felt bad or guilty about your use?
E – have you ever used or had a drink first thing in the morning as an eye-opener to
steady your nerves or feel normal?
23.
a. need to weigh clients at the same time of day
b. on the same scale
c. in the same clothes to allow an objective comparison of subsequent
weights
24. trauma to skin during care, exposure to pressure during immobilization, reaction
to various medications , neurologically impaired, chronically ill and orthopedic
clients, diminished mental status, poor tissue oxygenation, low cardiac output, or
inadequate nutrition
25. aggressive form of skin cancer
26. discolored skin that occurs unevenly, especially in the older adult
27. Answers can be found in Table 33-10.
28.
a. eczema
b. dermatitis
29. hardened
30. skin’s elasticity
31. areas of the skin swollen or edematous form a buildup of fluid in the tissues
32. thickening of the skin
33. ruby-red papules
34. Answers can be found in Box 33-8.
35.
a. pediculus humanus capitis (head lice)
b. pediculus humanus corporis (body lice)

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Answer Key to Study Guide 33-3

c. pediculus pubis (crab lice)

36. change in the angle between nail and nail base, softening and flattening and
enlargement of the fingertips
37. transverse depressions in nails
38. concave curves
39. splinter hemorrhages
40. inflammation of the skin at base of the nail
41. congenital anomaly or the buildup of cerebrospinal fluid in the ventricles
42. enlarged jaws and facial bones
43. a refractive error causing farsightedness
44. a refractive error causing nearsightedness
45. impaired near vision in middle-age and older adults, caused by loss of elasticity of the
lens
46. noninflammatory eye disorder resulting from changes in retinal blood vessels
47. congenital condition in which both eyes do not focus on an object simultaneously
48. increased opacity of the lens
49. intraocular structural damage resulting from increased intraocular pressure
50. blurred central vision often occurring suddenly, caused by progressive degeneration
of the center of the retina
51.
a. visual acuity
b. visual fields
c. extraocular movements
d. external eye structures
e. internal eye structures
52.
a. position and alignment
b. eyebrows
c. eyelids
d. lacrimal apparatus
e. conjunctivae
f. sclerae
g. pupils and irises
53. bulging eyes
54. lid margins that turn out
55. lid margins that turn in
56. presence of redness, which indicates and allergy or an infection
57. a thin white ring along the margin of the iris
58. pupils equal, round, reactive to light and accommodation
59. retina, choroids, optic nerve disc, macula, fovea centralis, and retinal vessels
60.
a. external (auricle, outer ear canal and tympanic membrane)
b. middle (3 bony ossicles)
c. inner ear (cochlea, vestibule, and semicircular canals)
61.
a. enter the external ear, pass through the outer ear canal

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Answer Key to Study Guide 33-4

b. waves reach the tympanic membrane (vibrate)

c. vibrations are transmitted through the middle ear by the bony occicular
chain to the oval window of the inner ear
d. cochlea receive the vibration
e. nerve impulses from the cochlea travel to the auditory nerve (8th) and to
the cerebral cortex
62.
a. conduction
b. sensorineural
c. mixed
63. lateralization of sound equally in both ears
64. comparison of air and bone conduction (AC>BC)
65. skin breakdown, characterized by redness and skin sloughing
66. tumor-like growths
67. thick white patches that are often precancerous lesions seen in heavy smokers and
alcoholics
68. swollen, tortuous veins that are common in the older adult
69. extra bony growth between the 2 palates
70. neck muscles, lymph nodes of the head and neck, carotid arteries, jugular veins,
thyroid gland, and trachea
71. sound waves that create vibrations that can be palpated externally
72. air movement through smaller airways that is soft, breezy, and low-pitched
73. air moving through larger airways that is blowing, medium-pitched, and intensity
74. air moving through trachea which is loud and high-pitched, with hollow quality
75. Answers can be found in Table 33-22.
76. apex touching the anterior chest wall at approximately the fourth to fifth intercostal
space, just medial to the left midclavicular line
77. Mitral and tricuspid valve closure causes the first heart sound.
78. Aortic and pulmonic valve closure causes the second heart sound.
79. rapid ventricular filling
80. Atria contract to enhance ventricular filling.
81. lies between the sternal body and manubrium and feels the ridge in the sternum
approximately 5 cm below the sternal notch
82. second intercostal space on the right
83. left second intercostal space
84. left third intercostal space
85. Fourth or fifth intercostal space along the sternum
86. Fifth intercostal space just to the left of the sternum, left midclavicular line
87. tip of the sternum
88. sustained swishing or blowing sounds heard at the beginning, middle, or end of the
systolic or diastolic phase
89.
a. auscultate all valve areas for placement in the cardiac cycle (timing),
where best heard (location) and radiation, loudness, pitch and quality
b. between S1 and S2 (systolic) and S2 and S1 (diastolic)
c. location is not necessarily over the valves

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Answer Key to Study Guide 33-5

d. assess for radiation

e. intensity or loudness and record in grading 1-6
f. low-pitched murmur best heard with the diaphragm
90. caused by a drop in heart rate and blood pressure
91. absent pulse wave (blockage)
92. diminished or unequal carotid pulsations
93. blood passing through a narrowed section, creating turbulence
94.
a. semi-Fowler’s position
b. expose the neck; align the head
c. lean client back into a supine position; level of venous pulsations begin to
rise as the patient reaches 45-degree angle
d. use 2 rulers
e. repeat the same measurement on the other side
95. Refer to Table 33-26 for the answers.
96. Inspect the calves for localized redness, tenderness, and swelling over vein sites.
97.
a. BSE monthly
b. women aged 20 years and older need to report any breast changes
c. clinical breast exam every 3 years (20-40) and yearly over the age of 40
d. family history: need a yearly exam
e. mammogram: age 40 annually (asymptomatic)
f. additional testing (increased risks)
98. spreading to the nodes
99. bilateral lumpy, painful breast, sometimes with nipple discharge
100. stretch marks
101. protusion of abdominal organs through the muscle wall
102. swelling by intestinal gas, tumor, or fluid in the abdominal cavity
103. movement of contents through the intestines, which is a
normal function of the small and large intestine
104. absent sounds that may indicate a lack of peristalsis
105. growling sounds, which are hyperactive bowel sounds
106. occurs in clients with peritoneal irritation
107. localized dilation of a vessel wall
108. syphilitic lesions, which appear as small,open ulcers that drain
serous material
109. a test for cervical and vaginal cancer
110. a painless enlargement of one testis and the appearance of a
palpable, small, hard lump on the side of the testicle
111. to detect colorectal cancer in the early stages and prostatic
tumors
112. hunchback, an exaggeration of the posterior curvature of the
thoracic spine
113. swayback, an increased lumbar curvature
114. lateral spinal curvature

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Answer Key to Study Guide 33-6

115. metabolic bone disease that causes a decrease in quality and

quantity of bone
116. measures the precise degree of motion in a particular joint
117. movement decreasing angle between 2 adjoining bones
118. increasing angle between 2 adjoining bones
119. beyond its normal resting extended position
120. that the frontal or ventral surfaces face downward
121. front or ventral surface faces upward
122. away from the midline
123. toward the midline
124. rotation of the joint inward
125. rotation of the joint outward
126. turning of the body part away from the midline
127. turning the body part toward the midline
128. flexion of toes and foot upward
129. bending of toes and foot downward
130. increased muscle tone
131. a muscle with little tone
132. a muscle reduced in size that feels soft and boggy
133. measures orientation and cognitive function
134. confusion, disorientation, and restlessness
135. an objective measurement of consciousness on a numerical scale
over time
136.
a. a person cannot understand written or verbal speech
b. a person understands written and verbal speech but cannot write or speak
appropriately when attempting to communicate
137.
a. olfactory
b. optic
c. oculomotor
d. trochlear
e. trigeminal
f. abducens
g. facial
h. auditory
i. glossopharyngeal
j. vagus
k. spinal accessory
l. hypoglossal
138. pain, temperature, position, vibration, and crude and finely localized
touch
139. pain, light touch, vibration, position, 2-point discrimination
140. Muscular activity maintains balance and equilibrium and helps to control
posture.
141.

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Answer Key to Study Guide 33-7

a. deep tendon reflexes (biceps, triceps, patellar, Achilles)

b. cutaneous reflexes (plantar, gluteal, abdominal)
142. 4. A thorough explanation of the purpose and steps of each assessment
lets clients know what to expect and what to do so that they can cooperate.
143. 3. normally the skin lifts easily and snaps back immediately to its resting
position; the back of the hand is not the best place to test for turgor
144. 3. circumscribed elevation of skin filled with serous fluid, smaller than 1
cm
145. 2. Use a systematic pattern when comparing the right and left sides. You
need to compare lung sounds in one region on one side of the body with sounds in
the same region on the opposite of the body.
146. 3. high-velocity airflow through severely narrowed or obstructed airway
147. 4. After the ventricles empty, ventricular pressure falls below that in the
aorta and pulmonary artery, allowing the valves to close and causing the second
heart sound.

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