Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

CHAPTER 25 HEALTH ASSESSMENT 145

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:

DEVELOPING YOUR

KNOWLEDGE BASE

IDENTIFICATION QUESTIONS

1.Locate the organs listed below that are found

in the anterior section of the abdominal

cavity. Place your answers on the lines

provided on the illustration below.

Sigmoid colon

Small intestine

Stomach

Appendix

Bladder

Spleen

Transverse colon

Ascending colon

Cecum

Liver

Descending colon

Midsternum

Midclavicular line

Aortic area

Mitral (apical)

area

Tricuspid

area

Erb's point

Pulmonic

area

a. __________

b. __________

c. __________

h. __________

d. __________

g. __________

e. __________

f. __________

i. __________

j. __________

k. __________

Anterior

d.Older adults may have an increased antero-

posterior chest diameter.

e.Older adults may have an increase in the

dorsal spinal curve (kyphosis).

f.Older adults may have increased thoracic

expansion.

8.Which of the following are recommended

guidelines for performing a peripheral vascular

assessment? (Select all that apply.)

a.Assessments are done by inspection and pal-

pation, with the patient sitting or supine.

b.The techniques used for cardiovascular

assessment include inspection, palpation,

and auscultation.

c.The hands are used to palpate the

precordium gently for pulsations using the

palmar surface with the four fingers spread

in a splayed position.

d.Auscultation used to determine the heart

sounds should be performed in a systematic

method, beginning at Erb’s point and mov-

ing to the tricuspid area, the mitral area, the

pulmonic area, and finally the aortic area.

e.During auscultation, the first heart sound is

heard as the “lub” of “lub-dub” and is

heard best at the apical area.

f.Bruits, which are normal heart sounds simi-

lar to murmurs, are heard over the major

blood vessels.

Hot Spot Question

1.Place an X on the figure below to mark the

spot where the nurse would auscultate to best

hear the S 1 heart sound.

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