Show Terms in this set (45)In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? -Inspection, palpation, percussion, auscultation Students also viewedRecommended textbook solutions
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Pharmacology: An Introduction8th EditionBarbara T Nagle, Hannah Ariel, Henry Hitner, Michele B. Kaufman, Yael Peimani-Lalehzarzadeh 1,355 solutions 1. When performing a physical assessment, what technique should the nurse always perform first? a. Palpation ANS: B The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system always begins with inspection. A focused inspection takes time and yields a surprising amount of information. 2. The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment? a. Usually yields little information ANS: B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doing something. It is more than a "quick glance." Train yourself not to rush through inspection by holding your hands behind your back. 3. The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to best assess the patient's skin temperature? a. Fingertips ANS: B The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination, not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not useful for palpation. 4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a. Palpation ANS: A Palpation uses the sense of touch to assess the patient for the factors in the question (texture, temperature, moisture, and swelling). Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing. 5. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? a. Avoid palpation of reportedly "tender" areas
because palpation in these areas may cause pain. ANS: D Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first. 6. The nurse would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant ANS: B Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation. 7. The nurse is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess? a. Turgor ANS: C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor, texture, and consistency are assessed with palpation. 8. The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene? a. Percussing once over each area ANS: A For percussion, the nurse should percuss 2 times over each location (not once). The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm. 9. While percussing over the liver of a patient, the nurse notices a dull sound. What should the nurse do? a. Consider this a normal finding. ANS: A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct. 10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. ANS: C The thickness of the person's body wall will be a factor. The nurse needs a stronger percussion stroke for people with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct. 11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. How should the nurse proceed? a. Palpate over the area for increased pain and tenderness. ANS: D Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a child's lung. There is no need to palpate for increased pain and tenderness; ask the child to take shallow breaths and percuss again; or refer the child to a specialist as loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a child's lung. 12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a. Count the patient's respirations. ANS: B Percussion is always available, portable, and offers instant feedback regarding changes in underlying tissue density, which may yield clues of the patient's physical status. 13. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a. Slope of the earpieces should point posteriorly (toward the occiput). ANS: B The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner's nose. The tubing length of a stethoscope should be 14 to 18 inches (36 to 46 cm). Tubing longer than this will distort sound. The fit and quality of the stethoscope are both important. 14. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? a. Used to listen for high-pitched sounds ANS: A The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be firmly held against the person's skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. 15. The nurse is preparing to auscultate the abdomen. How should the nurse proceed? a. Warm the endpiece of the stethoscope by placing it in warm water. ANS: D The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiner's hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds. 16. The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation ANS: A Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain. 17. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? a. Often used to direct light onto the sinuses ANS: D The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. An otoscope is not used to direct light on the sinuses and is not able to provide visualization of the structures of the internal ear. A short, broad speculum is used to visualize the nares, not the ear. 18. An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of these techniques by the examiner would indicate that the examination is being correctly performed? a. Rotating the lens selector dial to
bring the object into focus ANS: A The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus. 19. The nurse is unable to palpate the right radial pulse on a patient. What should the nurse do next? a. Auscultate over the area with a fetoscope. ANS: C Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds. When unable to palpate a pulse, a Doppler device should be used. 20. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? a. Performs the examination from the left side of the bed ANS: D The steps of the assessment should be organized to ensure that the patient does not change positions too often. The examiner will need to perform the examination on both sides of the bed in order to complete a full examination. Tender or painful areas should be assessed last. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiner's preference. 21. An adult male is at the clinic for a physical examination. He states that he is "very anxious" about the physical examination. What steps can the nurse take to make him more comfortable? a. Appear unhurried and confident when examining him. ANS: A Anxiety can be reduced by an examiner who is confident, self-assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the person's vital signs, will gradually accustom the person to the examination. 22. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a. Washing one's hands after removing gloves is not necessary, as long as the gloves are still intact. ANS: B The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact and gloves do not need to be worn throughout the entire exam but should be worn when potential contact with any body fluids is present. 23. The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a. Wash hands and then contact the physician. ANS: C The examiner should wear gloves when the potential contact with any body fluids is present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration. Although the nurse should wash his or her hands, there is no need to contact the physician at this point. The nurse should wash his or her hands immediately if they come into contact with bodily fluids and then apply gloves and continue the examination. The nurse should not change the order of the examination as an examiner should stick to his/her established system of examination so avoid omissions. 24. During the examination, offering some brief teaching about the patient's body or the examiner's findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. "Your atrial dysrhythmias are under control." ANS: C The sharing of some information builds rapport, as long as the patient is able to understand the terminology. Options A, B, and D use terminology that the patient may not understand. 25. While performing the physical examination, the nurse shares information and briefly teaches the patient. Why does the nurse do this? a. To help the examiner feel more comfortable and gain control of the situation ANS: B Sharing information builds rapport and increases the patient's confidence in the examiner. It also gives the patient a little more control in a situation during which feeling completely helpless is often present. Sharing information helps the patient, not the examiner, feel more comfortable and gain some control of the situation. It does not necessarily assist the patient's understanding of his/her disease process and treatment modalities or aid the patient in identifying questions or needed education. Sharing information during an examination does help build rapport and increase the patient's confidence in the examiner. 26. The nurse is preparing to examine an infant. At what point in the examination should the nurse attempt to elicit the Moro reflex? a. When the infant is
sleeping ANS: B The Moro or startle reflex is elicited at the end of the examination because it may cause the infant to cry. 27. Which should the nurse do when preparing to perform a physical examination on an infant? a. Have the parent remove all clothing except the diaper on
a boy. ANS: A Infants do not object to being nude so parents should remove the infant's clothing to allow for a thorough examination, but a diaper should be left on a boy. The timing of the examination should not be right after an infant has been fed but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. A pacifier may be used if the infant is crying or for invasive assessments but is not otherwise necessary for auscultation of the abdomen. The parent should always be present to increase the child's feeling of security and to understand normal growth and development. However, infants do not object to being nude so their clothing should be removed to allow for a thorough examination, but a diaper should be left on a boy 28. A 6-month-old infant has been brought to the well-child clinic for a checkup. She is currently sleeping. What should the nurse do first when beginning the examination? a. Wake the infant before beginning the examination. ANS: C When the infant is quiet or sleeping it is an ideal time to assess the cardiac, respiratory, and abdominal systems so the nurse does not need to wake the infant. Examining the infant's hips will likely wake the infant and would want to assess the heart and lungs before the infant wakes up. Assessment of the eye, ear, nose, and throat is an invasive procedure that should be performed at the end of the examination. 29. A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment? a. Ask the parent to place the child on the examining table. ANS: C The best place to examine the toddler is on the parent's lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time. 30. The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of the nurse's technique is most accurate? a. Asking questions enhances the child's autonomy. ANS: D Children at this age like to say, "No." Choices should not be offered when no choice is really available. If the child says, "No" and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, "Shall I listen to your heart next or your tummy?" Although asking for permission allows a choice and can enhance autonomy and develop some trust, it is not the best question for a 2-year-old child. 31. The nurse is preparing to examine a 4-year-old child. Which action by the nurse is appropriate for this age group? a. Explain the procedures in detail to alleviate the child's anxiety. ANS: B With preschool children, short, simple explanations should be used. Children at this age are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler. This is a preschool-aged child so the nurse should not explain procedures in detail as that will likely make the child anxious. Children at this age are usually willing to undress and should do so as needed for a thorough examination. An examination of the head should be performed last, not first. During the examination of a preschool-aged child, needed feedback and reassurance should be given to the child and short, simple explanations should be used. 32. What action by the nurse is appropriate when examining a 16-year-old male teenager? a. Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. ANS: D During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body image and often compares him or herself with peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development. Teens are very idealistic so they are ready for teaching, so the nurse should provide health teaching about wellness promotion. The adolescent should be examined alone, without a parent or sibling present. The nurse should not treat the adolescent like a child but should also not overestimate and treat him like an adult either. 33. When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. ANS: D When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially important with the older person because other senses may be diminished. When examining an older adult, the nurse should touch the patient as other senses may be diminished in the older adult. It is better to break the complete examination into a few visits than to rush through the examination. Although many older adults may have some hearing deficits, the nurse should not assume any hearing deficits. 34. What is the most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting? a. Wear protective eye wear at all times. ANS: C The most important step to decrease the risk for microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed. Wearing protective eye wear at all times or wearing gloves whenever in direct contact with patients is not necessary and is not the most important method to prevent transmission of microorganisms in the hospital setting. 35. Which of these statements is true regarding the use of Standard Precautions in the health care setting? a. Standard Precautions apply to all body fluids, including sweat. ANS: C Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat—regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. 36. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? a. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment. ANS: D Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessary. In this situation, having the patient lie down to perform assessments may worsen the shortness of breath. The nurse should examine the areas appropriate to the problem, in this case a respiratory and cardiac assessment, and the rest of the assessment can be completed later after the shortness of breath has resolved. Before obtaining a complete history from either the patient or a family member, the nurse should examine the areas appropriate to the problem, in this case a respiratory and cardiac assessment, first and the rest of the history and physical assessment can be completed later after the shortness of breath has resolved. 37. When examining an infant, the nurse should examine which area first? a. Ear ANS: D The least-distressing steps are performed first, saving the invasive steps of the examination of the eye, ear, nose, and throat until last. Examination of the ear, nose, and throat are considered more invasive and the invasive steps of the examination should be performed last. The least-distressing steps, such as examination of the abdomen, should be performed first. 38. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Electrocardiogram ANS: B An electrocardiogram and palpation are not used to assess murmurs. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds, not murmurs. The bell of the stethoscope is best for soft, low-pitched sounds such as murmurs, or extra heart sounds. 39. During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How should the nurse interpret this type of sound? a. Constipation ANS: B A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. Constipation and presence of a tumor or dense organ would have a muffled thud sound when percussing 40. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate? a. The child is asked to undress from the waist up. ANS: C A 6-year-old child has a sense of modesty. The child should undress him or herself, leaving underpants on and using a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from the child's head to the toes. 41. During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action should the nurse take? a. Ask the patient how he or she is feeling. ANS: D If an abnormal finding is not familiar, then the nurse may ask another examiner to double check the finding. Asking the patient how he/she feels, just documenting the findings, and auscultating again in 10 minutes do not help to identify the unfamiliar sound. 1. The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? (Select all that apply.) a. Identify any tender areas and palpate them last.
ANS: A, B, D, F The hands should always be warmed before beginning palpation. Intermittent pressure rather than one long continuous palpation is used; any tender areas are identified and palpated last. Fingertips are used to examine skin texture, swelling, pulsation, and the presence of lumps. The dorsa (backs) of the hands are used to assess skin temperature because the skin on the dorsa is thinner than on the palms. When using the diaphragm of the stethoscope the nurse knows?The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds? The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel sounds.
For which purpose would the nurse use a stethoscope during a physical examination?A stethoscope is a medical instrument that is used to listen to heart, lung, and other body sounds. It is also used to measure blood pressure. Nurses use stethoscopes to listen to their patients' heartbeats and to check for any abnormal sounds.
Which sound would the nurse Auscultate with the bell of the stethoscope?The bell of the stethoscope is best for picking up bruits. The diaphragm is more attuned to relatively high-pitched sounds; the bell is more sensitive to low-pitched sounds like bruits. When using the bell, apply it lightly over the area of the body you're listening to.
Which type of sound is Auscultated with the bell of the stethoscope quizlet?Which type of sounds is auscultated with the bell of the stethoscope? The bell of the stethoscope is a concave cup that best transmits low-pitched sounds. The nurse would hold the bell of the stethoscope very lightly on the skin to listen to low-pitched sounds such as heart murmurs.
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What does the nurse use the diaphragm of the stethoscope to best assess quizlet?
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