A nurse is performing a physical examination of a patient. How should the nurse examine the musculoskeletal system? Show Assessment of different body systems requires the use of different assessment techniques. While examining the musculoskeletal system, the nurse
should use the techniques of inspection and palpation. Palpation should be done to assess for masses and muscle spasms. Inspection can be used to assess any visual abnormality in the bones and muscles. Percussion involves producing sound and vibration to assess the underlying area, and may not be helpful in assessment of the musculoskeletal system. Auscultation helps in hearing the sounds produced by body organs such as the heart, lungs, and abdomen. A 10-year-old boy presents to the outpatient clinic after falling from a tree. This patient reports pain in his leg that radiates up to his knee. The nurse is concerned that the patient has fractured the distal portion of his fibula. Which question is best when conducting a symptom investigation of pain in this patient's leg? The best choice is asking the patient if there is anything that alleviates or aggravates the symptom. The nurse should remember the pneumonic PQRST: (P) Precipitative/Palliative, (Q) Quality, (R) Radiating, (S) Severity, (T) Timing. This pneumonic is helpful in obtaining more information from patients about specific symptoms they are feeling. Asking the patient if anything makes it worse or better is an example of (P) Precipitating/Palliative. Other questions may aid the nurse in gaining valuable information, but they are not symptom-specific. TEST-TAKING TIP: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is
in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best. A nurse works in an acute care unit. Which abnormality can be assessed through the technique of auscultation? Auscultation helps to listen to the sounds produced by the body with the help of a stethoscope. The murmur in the heart can be heard by auscultation. Hypothermia, organ enlargement, and muscular spasms can be assessed by the technique of palpation, which involves the use of light and deep touch to yield information. The nurse is performing a health history on the patient. Which
information will the nurse document as subjective data? "I feel nervous, nauseated, and hot" is correct because these are symptoms that are described or verified by the patient. Blood pressure is 136/84 is objective data. This is information that is observed or measured by the
health care provider. Pulses present in lower extremities is objective data that is measured using palpation. Right lower leg is reddened and warm to touch is objective data that is measured by observation using inspection and palpation. The nurse is preparing to perform an assessment. Which of these statements about the nursing assessment is true? The purpose of the nursing assessment is to enable the nurse to make clinical judgments or diagnoses about the patient's health status. Assessment is identified as the first step of the nursing process, but it is performed
continually throughout the nursing process to validate nursing diagnoses (not to diagnose a medical problem), evaluate nursing interventions, and determine whether patient outcomes and goals have been met. The nursing assessment consists of the health history and the physical assessment. The nursing assessment may not be delegated to unlicensed assistive personnel. After performing a complete health history and physical
examination on a patient, the nurse records the findings in the chart. Which of these is an example of an objective finding that the nurse would record? Objective data are data that the nurse has directly observed or inspected on
physical examination, such as vital signs. A pulse of 98 and a heart rate that is regular are examples of objective data. Subjective data are data that the nurse has received directly from the patient, such as a list of current prescriptions or any allergies. The patient's statement of "I feel weak and fatigued" is an example of subjective data. An 80-year-old patient is undergoing a physical examination. What measures
should the nurse implement to keep the patient comfortable during the examination? Select all that apply. While examining an elderly patient, the nurse should avoid
unnecessary changes in the position of the patient due to the limited range of motion of the extremities. The skin of the elder patient is fragile; therefore, it should be handled with care. As many tests as possible should be carried out in a comfortable position because repeated changes in position may be uncomfortable. Elderly patients have to be kept warm because they have less subcutaneous fat, which decreases their ability to keep their body warm. The patient should not be asked to perform
deep knee bends due to decreased reflexes and diminished sense of balance. During an admission history and physical assessment, the patient describes symptoms to the nurse. What type of data should these descriptions be documented as? Subjective data are collected by interviewing the patient and including
information that only can be described or verified by the patient. Objective data, or signs, are data that can be observed or measured. Although generalized data is not a terminology used in nursing, a general survey will be an observation of the general state of health of the patient. Comprehensive data could be accumulated in a comprehensive assessment which includes a detailed health history and physical examination of one body system or many body systems. A nurse is caring for a postoperative patient who has a surgical incision. Which technique should be used to examine the surgical wound? Inspection is the visual examination of a region or part of a body. Observing a particular region helps to determine if there is any alteration. A surgical wound can be examined by inspecting the wound alone.
Palpation can be used to assess masses, vibrations, swelling, and tenderness. Percussion is a technique that produces a specific sound and vibration to obtain information about the underlying area. Auscultation is used to listen to sounds produced in the body using a stethoscope. A nurse is reviewing the history reports of a patient. One of the reports reads, "Crackles in the apex of the left lung." Which technique of
physical assessment would yield this result? Crepitations in the apex of the left lung can be heard by using a stethoscope. This technique of hearing sounds produced in the body using a stethoscope is called auscultation. Palpation can be used to assess masses, vibrations, swelling, and tenderness. Inspection involves visual examination of the body part to determine abnormalities.
Percussion is a technique that produces a specific sound and vibration to obtain information about the underlying area. A nurse is performing a physical examination of a patient. Which assessment technique is appropriate for assessing bruits of the carotid artery? Bruits are a series of sounds which occur when
blood flows through the blood vessels. These sounds are assessed by using a stethoscope. Therefore, the nurse should auscultate the carotid artery for assessing bruit. Palpation involves the use of touch for assessment. Inspection involves direct observation of a body part. Percussion involves listening to hyperresonating sounds. These methods are not useful in assessing bruits. A nurse assesses that a patient has wheezes
in the apex of one lung. Which technique of physical assessment did the nurse use to make this determination? Auscultation is a technique in which a stethoscope is used to hear the sounds produced in the body. Wheezes produced at the apex of the right lung can be heard by auscultation. Inspection involves visual examination of a part or an area to determine any abnormalities.
Palpation involves examination of the body using touch. Percussion involves producing sound and vibration to obtain information about an underlying area of the body. A patient reports abdominal pain, vomiting, and diarrhea. The nurse determines that the patient's focused assessment should involve which body system? Abdominal pain, vomiting, and diarrhea are usually seen in gastrointestinal disorders. Most of the components of this system are localized in the abdominal region; therefore, the focused assessment should be performed on the abdomen. If the patient has complaints of cough, chest pain, palpitations, and breathlessness, then the focused assessment would involve the cardiac and respiratory system. Even though musculoskeletal system diseases may be present
with abdominal pain, they are not associated with vomiting and diarrhea. The nurse is performing a physical examination and is preparing to examine a patient's abdomen. Which of these reflects the proper order of the steps of an abdominal assessment? The proper order for abdominal assessment is: inspection, auscultation, percussion, and palpation. Performing percussion and palpation before auscultation can alter bowel sounds and produce false findings. A patient has chronic renal failure. During the assessment, the nurse makes note that there is pitting edema on one leg and that the texture of the skin overlying the edema has changed. Also, the temperature of the edematous area has increased. Which techniques of assessment has the nurse used to arrive at these findings? Select all that apply. 1 Palpation 1, 2 A patient admitted to the hospital with a fever, cold, and cough has been diagnosed with tuberculosis. Which assessment should the nurse perform after the diagnosis has been made? Focused assessment is a brief but specific assessment that focuses on the body system that is the focus of care. It
includes an assessment related to a specific problem, and monitors for signs of new problems. General assessment is a nonspecific assessment. Emergency assessment involves rapid examination and specific questioning of the patient. Comprehensive assessment involves detailed assessment of the body systems and includes a head-to-toe examination. By using the technique of palpation, the nurse can obtain what information about
a patient's thorax? 2 A nurse is performing a physical assessment on an older patient. What adaptations should the nurse make to ensure patient comfort? Select all that apply. 1, 3, 5 A nurse is providing care for a patient with narcolepsy. Which interventions should be included on the patient's treatment plan? Select all that apply. 1, 2, 4 During a physical examination, the nurse palpates the abdomen of the patient. What part of the hand should the nurse use
when performing the palpation? Finger tips are used when palpating the abdomen. It can provide information about presence of masses, pulsations, enlargement of organs, and tenderness. The palm proper is quite insensitive for assessing physical findings in a patient. The base of fingers of the palmar surface is sensitive for analyzing vibration sense. The dorsa of the hands are
sensitive for assessing temperature. The nurse is conducting an interview with a patient. Which response made by the nurse is most therapeutic? "I would like to ask you a few questions about what brought you here" is correct because the nurse needs to communicate acceptance of the patient by using an open, responsive, nonjudgmental approach. "I need information from you if you have some time to talk" does not open the patient up to talking about his or her problems and does not promote a trusting relationship. "It is really cold out today, isn't it? So how are you doing today?" does not
show that the health care provider is interested in the patient and does not indicate trust and respect. "I would like to ask your family questions about what brought you here" is incorrect because it is important for the nurse to determine the patient's priority concerns and expectations. It is important to communicate an acceptance of the patient as an individual by using an open responsive nonjudgmental approach. Creating a climate of trust and respect is critical to building a trusting
relationship. TEST-TAKING TIP: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. A patient has constipation. During physical examination, the nurse auscultates
the abdomen. Which is the most appropriate method for performing auscultation? Auscultation of the abdomen is useful in detecting high-pitched bowel sounds. The diaphragm of the stethoscope is sensitive in picking up
high-pitched sounds of the abdomen. The bell of the stethoscope is sensitive in detecting low-pitched sounds like heart murmurs. The interface of the bell and the diaphragm is less useful for clinical assessment. As the bowel sounds are high-pitched, the diaphragm should be held firmly on the skin during auscultation. A patient presents to the emergency department and reports abdominal pain radiating to the back that started 2 days ago. After completing an investigation of these symptoms, the nurse will begin an abdominal examination. Drag and drop the steps of the abdominal examination into their proper order. 1. Palpate the abdomen for masses or hepatomegaly. 4, 3, 2, 1 An 89-year-old patient has arthritis with inflamed joints. When performing the patient's physical assessment, what adaptations should the nurse make? Select all that apply. 1 Avoid having patient hop on one foot. 1, 3,
5 An elderly patient reports pain in the abdomen. When performing palpation of the liver on the patient, the nurse exercises caution by palpating lightly. What is the primary reason for the nurse exercising caution with this patient? 1 The patient has liver enlargement. 3 While interviewing a patient with a
history of chronic headache, a nurse asks, "Does the cold therapy make you feel better?" The nurse is assessing which characteristic of pain? 2 When performing a nursing history and physical assessment on an 85-year-old woman, which consideration should the nurse take into account because of this patient's age? 1 Ask the
patient to exhale forcefully and inhale gently. 2 TEST-TAKING TIP: Identify option components as correct or incorrect. This may help you identify a wrong
answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet). What are three things you can do to help make the patient comfortable during an exam?5 Ways to Help Ensure Patient Comfort in the Exam Room. Cleanliness and Order. A visibly clean and orderly exam room is vital to patient comfort. ... . Updated Upholstery & Equipment. ... . Accessibility to the Exam Table. ... . Ask Your Patient if They are Comfortable. ... . Make Eye Contact.. How do you make a patient feel comfortable?This article will provide you with tips to make your patients feel even more comfortable whenever they come to see you.. Listen to your Patient. ... . Create a Welcoming Environment. ... . Educate Your Patients. ... . Follow-up with Patients. ... . Spend Time Your Patients. ... . Be Positive. ... . Look After Yourself.. What are some of the comfort and safety measures that you could provide to a patient?5 Factors that can help improve patient safety in hospitals. Use monitoring technology. ... . Make sure patients understand their treatment. ... . Verify all medical procedures. ... . Follow proper handwashing procedures. ... . Promote a team atmosphere.. What strategies do you use for putting a patient at ease?Top Tips For Making the Patient Feel At Ease. Acknowledge the patient as they enter the room – try not to have your back to them – make a clever remark if they have to wait (Don't you run away). Greet the patient with your smile and cheerful voice.. Give direct eye contact.. |
What interventions can help make the patient more comfortable during the physical examination?
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