Chapter 21: Physical Assessment - Nurselytic

Questions 49

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Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills

Chapter 21 : Physical Assessment Questions

Question 1 of 5

The acronym CTA stands for what? Which means what?

Correct Answer: A

Rationale: CTA stands for 'clear to auscultation,' indicating normal lung sounds with no abnormalities.

Question 2 of 5

The acronym PMI stands for what? Which means what?

Correct Answer: A

Rationale: PMI stands for 'point of maximum impulse,' the location where the heart's apex beat is strongest, typically at the 5th intercostal space.

Question 3 of 5

Explain the importance of performing an initial shift assessment within the first hour of your shift.

Correct Answer: D

Rationale: An initial shift assessment within the first hour establishes a baseline, detects changes, and guides care planning.

Question 4 of 5

What assessments should you make of the lower extremities in an initial shift assessment?

Correct Answer: D

Rationale: Lower extremity assessment includes pulse strength, edema, skin condition, range of motion, capillary refill, temperature, sensation, strength, color, and mobility.

Question 5 of 5

Describe the assessments that should be performed in relation to these limited data.

Correct Answer: D

Rationale: For a dehydrated, bedridden patient, assess skin turgor, mucous membranes, pressure ulcer risk, capillary refill, weight, urine output, edema, skin integrity, and mobility.

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