EXAM 2:NUR 3121 Health Assessment
Unit LATEST
When performing a physical assessment, the technique the nurse will always use first
is: - ANSWERSANS: inspection.
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, where auscultation takes place before
palpation and percussion). The assessment of each body system begins with
inspection. A focused inspection takes time and yields a surprising amount of
information.
The nurse is preparing to perform a physical assessment. Which statement is true
about the inspection phase of the physical assessment? - ANSWERSANS: Inspection
takes time and reveals a surprising amount of information.
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." A focused assessment is much more than a "quick glance."
The nurse is assessing a patient's skin during an office visit. What is the best technique
to use to best assess the patient's skin temperature? Use the: - ANSWERSANS: dorsal
surface of the hand because the skin is thinner than on the palms.
The dorsa (backs) of hands and fingers are best for determining temperature because
the skin there is thinner than on the palms. Fingertips are best for fine, tactile
discrimination; the other responses are not useful for palpation.
Which of these techniques uses the sense of touch to assess texture, temperature,
moisture, and swelling when the nurse is assessing a patient? - ANSWERSANS:
Palpation
Palpation uses the sense of touch to assess the patient for these factors. Inspection
involves vision; percussion assesses through the use of palpable vibrations and audible
sounds; and auscultation uses the sense of hearing.
The nurse is preparing to assess a patient's abdomen by palpation. How should the
nurse proceed? - ANSWERSANS: Start with light palpation to detect surface
characteristics and to accustom the patient to being touched.
Light palpation is performed initially to detect any surface characteristics and to
accustom the person to being touched. Tender areas should be palpated last, not first.
,The nurse would use bimanual palpation technique in which situation? -
ANSWERSANS: Palpating the kidneys and uterus
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.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the
percussion is to assess the underlying tissue: - ANSWERSANS: density.
Percussion yields a sound that depicts the location, size, and density of the underlying
organ. Turgor and texture are assessed with palpation.
The nurse is reviewing percussion techniques with a newly graduated nurse. Which
technique, if used by the new nurse, indicates that more review is needed? The nurse: -
ANSWERSANS: percusses once over each area.
For percussion, the nurse should percuss two times over each location. The striking
finger should be lifted off quickly 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 it is used to make the strikes, not the arm.
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse
should: - ANSWERSANS: consider this a normal finding.
Percussion over relatively dense organs, such as the liver or spleen, will produce a dull
sound. The other responses are not correct.
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? - ANSWERSANS:
Increase the amount of strength used when attempting to percuss over the abdomen.
The thickness of the person's body wall will be a factor. The nurse will need a stronger
percussion stroke for persons with obese or very muscular body walls. The force of the
blow determines the loudness of the note. The other actions are not correct.
The nurse hears bilateral louder, longer, and lower tones when percussing over the
lungs of a 4-year-old child. What should the nurse do next? - ANSWERSANS: Consider
this a normal finding for a child this age and proceed with the examination.
Percussion notes that are louder in amplitude, lower in pitch, of a booming quality, and
longer in duration are normal over a child's lung.
A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After putting a call in to the physician and placing the patient on
oxygen, which of these is the best action for the nurse to take when assessing the
, patient further? - ANSWERSANS: Percuss the thorax bilaterally, noting any differences
in percussion tones.
Percussion is always available, portable, and gives instant feedback regarding changes
in underlying tissue density, which may yield clues of the patient's physical status.
The nurse is teaching a class on basic assessment skills. Which of these statements is
true regarding the stethoscope and its use? - ANSWERSANS: The stethoscope does
not magnify sound but does block out extraneous room noise.
The stethoscope does not magnify sound but does block out extraneous room sounds.
The slope of the earpieces should point forward toward the examiner's nose. Longer
tubing will distort sound. The fit and quality of the stethoscope are important.
The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm: - ANSWERSANS: is used
to listen for high-pitched sounds.
The diaphragm of the stethoscope is best for listening to high-pitched sounds such as
breath, bowel, and normal heart sounds. It should be held firmly 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.
Before auscultating the abdomen for the presence of bowel sounds on a patient, the
nurse should: - ANSWERSANS: check the temperature of the room and offer blankets
to the patient if he or she feels cold.
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.
The nurse will use which technique of assessment to determine the presence of
crepitus, swelling, and pulsations? - ANSWERSANS: Palpation
Palpation applies the sense of touch to assess these factors: 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 presence of tenderness or
pain.
The nurse is preparing to use an otoscope for an examination. Which statement is true
regarding the otoscope? The otoscope: - ANSWERSANS: directs light into the ear canal
and onto the tympanic membrane.
Unit LATEST
When performing a physical assessment, the technique the nurse will always use first
is: - ANSWERSANS: inspection.
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, where auscultation takes place before
palpation and percussion). The assessment of each body system begins with
inspection. A focused inspection takes time and yields a surprising amount of
information.
The nurse is preparing to perform a physical assessment. Which statement is true
about the inspection phase of the physical assessment? - ANSWERSANS: Inspection
takes time and reveals a surprising amount of information.
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." A focused assessment is much more than a "quick glance."
The nurse is assessing a patient's skin during an office visit. What is the best technique
to use to best assess the patient's skin temperature? Use the: - ANSWERSANS: dorsal
surface of the hand because the skin is thinner than on the palms.
The dorsa (backs) of hands and fingers are best for determining temperature because
the skin there is thinner than on the palms. Fingertips are best for fine, tactile
discrimination; the other responses are not useful for palpation.
Which of these techniques uses the sense of touch to assess texture, temperature,
moisture, and swelling when the nurse is assessing a patient? - ANSWERSANS:
Palpation
Palpation uses the sense of touch to assess the patient for these factors. Inspection
involves vision; percussion assesses through the use of palpable vibrations and audible
sounds; and auscultation uses the sense of hearing.
The nurse is preparing to assess a patient's abdomen by palpation. How should the
nurse proceed? - ANSWERSANS: Start with light palpation to detect surface
characteristics and to accustom the patient to being touched.
Light palpation is performed initially to detect any surface characteristics and to
accustom the person to being touched. Tender areas should be palpated last, not first.
,The nurse would use bimanual palpation technique in which situation? -
ANSWERSANS: Palpating the kidneys and uterus
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.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the
percussion is to assess the underlying tissue: - ANSWERSANS: density.
Percussion yields a sound that depicts the location, size, and density of the underlying
organ. Turgor and texture are assessed with palpation.
The nurse is reviewing percussion techniques with a newly graduated nurse. Which
technique, if used by the new nurse, indicates that more review is needed? The nurse: -
ANSWERSANS: percusses once over each area.
For percussion, the nurse should percuss two times over each location. The striking
finger should be lifted off quickly 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 it is used to make the strikes, not the arm.
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse
should: - ANSWERSANS: consider this a normal finding.
Percussion over relatively dense organs, such as the liver or spleen, will produce a dull
sound. The other responses are not correct.
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? - ANSWERSANS:
Increase the amount of strength used when attempting to percuss over the abdomen.
The thickness of the person's body wall will be a factor. The nurse will need a stronger
percussion stroke for persons with obese or very muscular body walls. The force of the
blow determines the loudness of the note. The other actions are not correct.
The nurse hears bilateral louder, longer, and lower tones when percussing over the
lungs of a 4-year-old child. What should the nurse do next? - ANSWERSANS: Consider
this a normal finding for a child this age and proceed with the examination.
Percussion notes that are louder in amplitude, lower in pitch, of a booming quality, and
longer in duration are normal over a child's lung.
A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After putting a call in to the physician and placing the patient on
oxygen, which of these is the best action for the nurse to take when assessing the
, patient further? - ANSWERSANS: Percuss the thorax bilaterally, noting any differences
in percussion tones.
Percussion is always available, portable, and gives instant feedback regarding changes
in underlying tissue density, which may yield clues of the patient's physical status.
The nurse is teaching a class on basic assessment skills. Which of these statements is
true regarding the stethoscope and its use? - ANSWERSANS: The stethoscope does
not magnify sound but does block out extraneous room noise.
The stethoscope does not magnify sound but does block out extraneous room sounds.
The slope of the earpieces should point forward toward the examiner's nose. Longer
tubing will distort sound. The fit and quality of the stethoscope are important.
The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm: - ANSWERSANS: is used
to listen for high-pitched sounds.
The diaphragm of the stethoscope is best for listening to high-pitched sounds such as
breath, bowel, and normal heart sounds. It should be held firmly 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.
Before auscultating the abdomen for the presence of bowel sounds on a patient, the
nurse should: - ANSWERSANS: check the temperature of the room and offer blankets
to the patient if he or she feels cold.
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.
The nurse will use which technique of assessment to determine the presence of
crepitus, swelling, and pulsations? - ANSWERSANS: Palpation
Palpation applies the sense of touch to assess these factors: 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 presence of tenderness or
pain.
The nurse is preparing to use an otoscope for an examination. Which statement is true
regarding the otoscope? The otoscope: - ANSWERSANS: directs light into the ear canal
and onto the tympanic membrane.
