NUR 414 EXAM 1 QUESTIONS & ANSWERS
Assessment is the first step in the nursing process, and it is critical that an accurate
assessment is obtained in order to diagnose, plan, implement, and evaluate the plan of
care. The four basic techniques of the physical examination are : - answers -
inspection, palpation, percussion, and auscultation.
Inspection has two parts: - answers - general inspection and systematic inspection
General inspection - answers - observing the patient from front to back and from each
side, checking for symmetry of body parts, obvious injuries or abnormalities, and overall
appearance
Systematic inspection - answers - inspecting each body region systematically from
head-to-toe. This is also called a head-to-toe assessment
Guidelines for inspection include: - answers - 1. Having adequate lighting—daylight or
artificial
2. Conducting unhurried and careful inspection
3. Exposing what you want to inspect
4. Validating findings with patient
5. Ensuring appropriate equipment is available
When conducting the assessment of a new patient, inspection begins with which step? -
answers - general inspection of the patient
Which steps are required to conduct accurate inspection? - answers - 1. Validate
findings with the patient
2. Expose the area being inspected
3. Ensure adequate lighting is available
What is included as part of the general inspection? - answers - observing overall
appearance of patient
Which component is included as part of a systematic inspection? - answers -
inspecting each body region from head to toe
Palpitation - answers - involves using the hands and fingers to gather assessment data
through touch. It is used to gather information about skin temperature, pulsations or
vibrations, size of organs, and tenderness of internal structures.
Guidelines for palpation include: - answers - 1. Keep fingernails short to avoid hurting
the patient.
2. Have warm hands and be gentle in approach to assist the patient in relaxing in order
to obtain more accurate data.
, 3. Use correct palpation depth and the appropriate part of the hand to correctly identify
findings without producing unnecessary discomfort to the patient.
When assessing the abdomen, always perform __ - answers - palpation after
inspection and auscultation.
Gloves should be worn for palpating areas where __ - answers - contact with body
fluids is possible (genitalia or wounds) or when palpating mucous membranes.
Palpitation: palmar surface of the fingers and finger pads - answers - used to
determine position, texture, size, consistency, fluid, crepitus, form of a mass, or
structure
Palpitation: ulnar surfaces of hand and fingers - answers - used to assess vibrations
Palpitation: dorsal surface of hand - answers - used to asses temperature
Palpitation: entire hand - answers - used to asses muscle strength
Light palpation - answers - accomplished by pressing down to a depth of
approximately 1 cm and is used to assess moisture, texture, temperature, pulsations,
tenderness, and superficial masses and lesions
Deep palpation - answers - accomplished by pressing down to a depth of 4 cm with
one or two hands and is used to determine organ size and contour, especially of the
liver.
Bimanual palpation - answers - can be used for light or deep palpation. Bimanual
palpation uses both hands to entrap a mass or an organ (such as the uterus, kidney, or
large breasts) between the fingertips to assess size and shape.
Light palpation is best used to obtain which assessment data?
- uterine firmness
- moisture of skin
- liver shape and size
- distention of colon - answers - moisture of skin
Bimanual palpation is best used to assess which area of the body?
- liver and large intestine
- female reproductive organs
- pulsations of femoral artery
- skin of the posterior thorax - answers - female reproductive organs
Match the following assessment with the part of the hand best suited to obtain accurate
assessment data. - answers - finger pads = eliciting reflexes
Ball of hand = grip and strength
Assessment is the first step in the nursing process, and it is critical that an accurate
assessment is obtained in order to diagnose, plan, implement, and evaluate the plan of
care. The four basic techniques of the physical examination are : - answers -
inspection, palpation, percussion, and auscultation.
Inspection has two parts: - answers - general inspection and systematic inspection
General inspection - answers - observing the patient from front to back and from each
side, checking for symmetry of body parts, obvious injuries or abnormalities, and overall
appearance
Systematic inspection - answers - inspecting each body region systematically from
head-to-toe. This is also called a head-to-toe assessment
Guidelines for inspection include: - answers - 1. Having adequate lighting—daylight or
artificial
2. Conducting unhurried and careful inspection
3. Exposing what you want to inspect
4. Validating findings with patient
5. Ensuring appropriate equipment is available
When conducting the assessment of a new patient, inspection begins with which step? -
answers - general inspection of the patient
Which steps are required to conduct accurate inspection? - answers - 1. Validate
findings with the patient
2. Expose the area being inspected
3. Ensure adequate lighting is available
What is included as part of the general inspection? - answers - observing overall
appearance of patient
Which component is included as part of a systematic inspection? - answers -
inspecting each body region from head to toe
Palpitation - answers - involves using the hands and fingers to gather assessment data
through touch. It is used to gather information about skin temperature, pulsations or
vibrations, size of organs, and tenderness of internal structures.
Guidelines for palpation include: - answers - 1. Keep fingernails short to avoid hurting
the patient.
2. Have warm hands and be gentle in approach to assist the patient in relaxing in order
to obtain more accurate data.
, 3. Use correct palpation depth and the appropriate part of the hand to correctly identify
findings without producing unnecessary discomfort to the patient.
When assessing the abdomen, always perform __ - answers - palpation after
inspection and auscultation.
Gloves should be worn for palpating areas where __ - answers - contact with body
fluids is possible (genitalia or wounds) or when palpating mucous membranes.
Palpitation: palmar surface of the fingers and finger pads - answers - used to
determine position, texture, size, consistency, fluid, crepitus, form of a mass, or
structure
Palpitation: ulnar surfaces of hand and fingers - answers - used to assess vibrations
Palpitation: dorsal surface of hand - answers - used to asses temperature
Palpitation: entire hand - answers - used to asses muscle strength
Light palpation - answers - accomplished by pressing down to a depth of
approximately 1 cm and is used to assess moisture, texture, temperature, pulsations,
tenderness, and superficial masses and lesions
Deep palpation - answers - accomplished by pressing down to a depth of 4 cm with
one or two hands and is used to determine organ size and contour, especially of the
liver.
Bimanual palpation - answers - can be used for light or deep palpation. Bimanual
palpation uses both hands to entrap a mass or an organ (such as the uterus, kidney, or
large breasts) between the fingertips to assess size and shape.
Light palpation is best used to obtain which assessment data?
- uterine firmness
- moisture of skin
- liver shape and size
- distention of colon - answers - moisture of skin
Bimanual palpation is best used to assess which area of the body?
- liver and large intestine
- female reproductive organs
- pulsations of femoral artery
- skin of the posterior thorax - answers - female reproductive organs
Match the following assessment with the part of the hand best suited to obtain accurate
assessment data. - answers - finger pads = eliciting reflexes
Ball of hand = grip and strength
