Clinical Nursing Practice; chapter 6
skills review
The nurse is visiting the patient for the first time this shift. She introduces herself and
asks the patient
several questions related to his condition. While doing so, and without being obvious,
she is looking at
the color of his eyes and is assessing his ears and nose for discharge and the
symmetry of his mouth.
Which assessment technique is the nurse using?
a. Palpation
b. Percussion
c. Inspection
d. Auscultation - ANS>>c. Inspection
Rationale: Inspection is the visual examination of body parts or areas. An experienced
nurse learns to make
multiple observations, almost simultaneously, while becoming very perceptive of
abnormalities.
Palpation uses the sense of touch. Percussion involves tapping the body with the
fingertips to evaluate
the size, borders, and consistency of body organs and to discover fluid in body cavities.
Auscultation is
listening with a stethoscope to sounds produced by the body.
The patient is admitted with fever and acute lower abdominal pain. He has taken
Tylenol but says he
still feels feverish. Before taking the patient's temperature, the nurse may:
a. touch the patient's skin with the dorsum of her hand.
b. touch the patient's skin with the pads of her fingers.
c. palpate the skin using the bimanual method.
d. tap the patient's skin using the fingertips. - ANS>>a. touch the patient's skin with the
dorsum of her hand.
Rationale: The dorsum (back) of the hand is more sensitive to temperature variations.
The pads of the fingertips
detect subtle changes in texture, shape, size, consistency, and pulsation of body parts.
Bimanual
palpation involves one hand placed over the other while pressure is applied. The upper
hand exerts
,downward pressure as the other hand feels the subtle characteristics of underlying
organs and masses.
Seek the assistance of a qualified instructor before attempting deep palpation.
Percussion involves
tapping the body with the fingertips to evaluate the size, borders, and consistency of
body organs and
to discover fluid in body cavities.
What should the nurse do when preparing to complete an assessment for a 16-year-old
patient?
a. Focus on illness behaviors.
b. Plan for a diminished energy level.
c. Treat the patient as an individual.
d. Have the parents present throughout. - ANS>>c. Treat the patient as an individual.
Rationale: Older children and adolescents tend to respond best when treated as adults
and individuals and often
can provide details about their health history and severity of symptoms. Routine
examinations of
children have a focus on health promotion and illness prevention, particularly in the care
of well
children with competent parenting and no serious health problems. The focus is on
growth and
development, sensory screening, dental examination, and behavioral assessment.
Children who are
chronically ill, disabled, in foster care, or foreign-born adopted may require additional
assessment. The
adolescent has a right to confidentiality. After talking with the parents about historical
information, the
nurse arranges to be alone with the adolescent to speak further privately and to perform
the
examination.
The general survey begins with a review of the patient's primary health problems and an
evaluation of
the patient's vital signs, height and weight, general behavior, and appearance. It also
provides
information about the patient's illness, hygiene, skin condition, body image, and
emotional state.
Which of the following cannot be delegated to nursing assistive personnel?
a. Reporting subjective signs and symptoms
b. Measuring the patient's height and weight
c. Monitoring I&O
d. Obtaining initial vital signs - ANS>>d. Obtaining initial vital signs
, Rationale: Because the initial set of vital signs are part of the general health
assessment they must be taken by the
nurse. After that the NAP may take vital signs for a stable patient. The nurse directs
NAP to report a
patient's subjective signs and symptoms to the nurse, to measure the patient's height
and weight, and
to monitor oral intake and urinary output.
Petechiae are noted on the patient as a result of the nurse finding:
a. bluish-black patches.
b. tenting.
c. pinpoint-sized red dots.
d. large areas of raised, irritated skin. - ANS>>c. pinpoint-sized red dots.
Rationale: Petechiae appear as tiny, pinpoint-sized, red or purple spots on the skin
caused by small hemorrhages
in the skin layers and may indicate a blood-clotting disorder, a drug reaction, or liver
disease. Bluish-
black patches are more indicative of malignant melanoma. With reduced turgor, the skin
remains
suspended or "tented" for a few seconds before slowly returning to place. This indicates
decreased
elasticity and possible dehydration. Large areas of raised, irritated skin are not
characteristic of
petechiae.
The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices
that the skin
remains suspended for a longer than normal period. What could this indicate?
a. Stage 1 pressure ulcer
b. Increased blood flow to the area
c. Localized vasodilation
d. Dehydration - ANS>>d. Dehydration
Rationale: With reduced turgor, the skin remains suspended or "tented" for a few
seconds before slowly returning
to place. This indicates decreased elasticity and possible dehydration. A stage 1
pressure ulcer may
cause warmth and erythema (redness) of an area. Skin temperature reflects an
increase or decrease in
blood flow. Normal reactive hyperemia (redness) is a visible effect of localized
vasodilation, the
body's normal response to lack of blood flow to underlying tissue.
skills review
The nurse is visiting the patient for the first time this shift. She introduces herself and
asks the patient
several questions related to his condition. While doing so, and without being obvious,
she is looking at
the color of his eyes and is assessing his ears and nose for discharge and the
symmetry of his mouth.
Which assessment technique is the nurse using?
a. Palpation
b. Percussion
c. Inspection
d. Auscultation - ANS>>c. Inspection
Rationale: Inspection is the visual examination of body parts or areas. An experienced
nurse learns to make
multiple observations, almost simultaneously, while becoming very perceptive of
abnormalities.
Palpation uses the sense of touch. Percussion involves tapping the body with the
fingertips to evaluate
the size, borders, and consistency of body organs and to discover fluid in body cavities.
Auscultation is
listening with a stethoscope to sounds produced by the body.
The patient is admitted with fever and acute lower abdominal pain. He has taken
Tylenol but says he
still feels feverish. Before taking the patient's temperature, the nurse may:
a. touch the patient's skin with the dorsum of her hand.
b. touch the patient's skin with the pads of her fingers.
c. palpate the skin using the bimanual method.
d. tap the patient's skin using the fingertips. - ANS>>a. touch the patient's skin with the
dorsum of her hand.
Rationale: The dorsum (back) of the hand is more sensitive to temperature variations.
The pads of the fingertips
detect subtle changes in texture, shape, size, consistency, and pulsation of body parts.
Bimanual
palpation involves one hand placed over the other while pressure is applied. The upper
hand exerts
,downward pressure as the other hand feels the subtle characteristics of underlying
organs and masses.
Seek the assistance of a qualified instructor before attempting deep palpation.
Percussion involves
tapping the body with the fingertips to evaluate the size, borders, and consistency of
body organs and
to discover fluid in body cavities.
What should the nurse do when preparing to complete an assessment for a 16-year-old
patient?
a. Focus on illness behaviors.
b. Plan for a diminished energy level.
c. Treat the patient as an individual.
d. Have the parents present throughout. - ANS>>c. Treat the patient as an individual.
Rationale: Older children and adolescents tend to respond best when treated as adults
and individuals and often
can provide details about their health history and severity of symptoms. Routine
examinations of
children have a focus on health promotion and illness prevention, particularly in the care
of well
children with competent parenting and no serious health problems. The focus is on
growth and
development, sensory screening, dental examination, and behavioral assessment.
Children who are
chronically ill, disabled, in foster care, or foreign-born adopted may require additional
assessment. The
adolescent has a right to confidentiality. After talking with the parents about historical
information, the
nurse arranges to be alone with the adolescent to speak further privately and to perform
the
examination.
The general survey begins with a review of the patient's primary health problems and an
evaluation of
the patient's vital signs, height and weight, general behavior, and appearance. It also
provides
information about the patient's illness, hygiene, skin condition, body image, and
emotional state.
Which of the following cannot be delegated to nursing assistive personnel?
a. Reporting subjective signs and symptoms
b. Measuring the patient's height and weight
c. Monitoring I&O
d. Obtaining initial vital signs - ANS>>d. Obtaining initial vital signs
, Rationale: Because the initial set of vital signs are part of the general health
assessment they must be taken by the
nurse. After that the NAP may take vital signs for a stable patient. The nurse directs
NAP to report a
patient's subjective signs and symptoms to the nurse, to measure the patient's height
and weight, and
to monitor oral intake and urinary output.
Petechiae are noted on the patient as a result of the nurse finding:
a. bluish-black patches.
b. tenting.
c. pinpoint-sized red dots.
d. large areas of raised, irritated skin. - ANS>>c. pinpoint-sized red dots.
Rationale: Petechiae appear as tiny, pinpoint-sized, red or purple spots on the skin
caused by small hemorrhages
in the skin layers and may indicate a blood-clotting disorder, a drug reaction, or liver
disease. Bluish-
black patches are more indicative of malignant melanoma. With reduced turgor, the skin
remains
suspended or "tented" for a few seconds before slowly returning to place. This indicates
decreased
elasticity and possible dehydration. Large areas of raised, irritated skin are not
characteristic of
petechiae.
The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices
that the skin
remains suspended for a longer than normal period. What could this indicate?
a. Stage 1 pressure ulcer
b. Increased blood flow to the area
c. Localized vasodilation
d. Dehydration - ANS>>d. Dehydration
Rationale: With reduced turgor, the skin remains suspended or "tented" for a few
seconds before slowly returning
to place. This indicates decreased elasticity and possible dehydration. A stage 1
pressure ulcer may
cause warmth and erythema (redness) of an area. Skin temperature reflects an
increase or decrease in
blood flow. Normal reactive hyperemia (redness) is a visible effect of localized
vasodilation, the
body's normal response to lack of blood flow to underlying tissue.
