Chapter 20, Health History and Physical Assessment

Which assessment in a patient requires the nurse to use the back of the hand? 1 Size of a body part 2. Texture of a body part 3. Position of a body part 4. Temperature of a body part - Correct 4 Temperature of a body part The nurse uses the back of his or her hand to assess the temperature of the patient. This is because the skin on the back of the hand is thinner than the skin on the palm of the hand and it is more sensitive to temperature. The nurse assesses the size and position of a body part using the palmar surfaces of the fingers and finger pads. The nurse should use his or her fingertips to assess the texture, vibration, or pulsations. Which of the following physical examination techniques are most helpful when assessing a patient? Select all that apply. A. Palpation B. Evaluation C. Percussion D.Visualization E. Auscultation - A, C, E Palpation, percussion, and auscultation are all techniques the nurse uses during a physical examination. Palpation refers to assessing by touch. Percussion involves assessment by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to body sounds to detect variations from normal functioning. Evaluation and visualization are not formal techniques of physical examination. Turgor is related to the elasticity of the skin. What is the effect on the skin when a patient has poor turgor? 1. The skin stays pinched. 2. The skin has an edematous area. 3. The skin has ruby red papules. 4. The skin falls immediately back to its original position. - Correct 1. The skin stays pinched. In poor turgor, the skin stays pinched. An edematous area is observed in the case of skin edema. Ruby red papules on the skin indicate skin lesions. The normal skin falls immediately back to its original position. During a physical examination, which area of the body should the nurse assess for cyanosis in a patient? Select all that apply. A. Mucous membranes B. Skin C. Sclera of the eye D. Nail beds E. Inside the throat - Correct A, B, D In cyanosis, deoxygenated hemoglobin increases in the body and produces a bluish discoloration of the skin and mucous membranes. For the assessment of cyanosis, the skin, nailbeds, and mucous membranes are observed. Cyanosis is not found in the sclera of the eye. The inside of the throat is not the best place to assess for cyanosis because it is the least accessible area that can reliably show bluish discoloration.