Chapter 5 Affective Changes
MULTIPLE CHOICE
1. When performing a physical assessment, the first technique the nurse will
always
use is:
a.
d. Auscultation.
ANS: B
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, during which 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.
2. The nurse is preparing to perform a physical assessment. Which statement
is true about the physical assessment? The inspection phase:
a. Usually yields little information.
b. Takes time and reveals a surprising amount of information.
c. May be somewhat uncomfortable for the expert practitioner.
d. Requires a quick glance at the patients body systems before proceeding
with palpation.
ANS: B
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 significantly more than a quick
glance.
3. The nurse is assessing a patients skin during an office visit. What part of the
hand
and technique should be used to best assess the patients skin temperature?
a. Fingertips; they are more sensitive to small changes in temperature.
b. Dorsal surface of the hand; the skin is thinner on this surface than on the
palms.
c. Ulnar portion of the hand; increased blood supply in this area enhances
temperature sens
Palmar surface of the hand; this surface is the most sensitive to
temperature variations b
, d. of its increased nerve supply in this area.
ANS:
B
The dorsa (backs) of the hands and fingers are best for determining temperature
because the skin is thinner on the dorsal surfaces than on the palms.
Fingertips are best for fine, tactile discrimination. The other
responses are not useful for palpation.
, 4. Which of these techniques uses the sense of touch to assess texture,
temperature,
moisture, and swelling when the nurse is assessing a patient?
a.
d. Auscultation
ANS: A
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.
5. The nurse is preparing to assess a patients abdomen by palpation. How should
the
nurse proceed?
Palpation of reportedly tender areas are avoided because palpation in
these areas may ca
a. pain.
Palpating a tender area is quickly performed to avoid any discomfort that
the patient ma
b. experience.
The assessment begins with deep palpation, while encouraging the patient
to relax and to
c. deep breaths.
The assessment begins with light palpation to detect surface
characteristics and to accust
d. patient to being touched.
ANS:
D
Light palpation is initially performed to detect any surface
characteristics and to accustom the person to being touched. Tender
areas should be palpated last, not first.
6. The nurse would use bimanual palpation technique in which situation?
a. Palpating the thorax of an infant
b. Palpating the kidneys and uterus
c. Assessing pulsations and vibrations
MULTIPLE CHOICE
1. When performing a physical assessment, the first technique the nurse will
always
use is:
a.
d. Auscultation.
ANS: B
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, during which 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.
2. The nurse is preparing to perform a physical assessment. Which statement
is true about the physical assessment? The inspection phase:
a. Usually yields little information.
b. Takes time and reveals a surprising amount of information.
c. May be somewhat uncomfortable for the expert practitioner.
d. Requires a quick glance at the patients body systems before proceeding
with palpation.
ANS: B
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 significantly more than a quick
glance.
3. The nurse is assessing a patients skin during an office visit. What part of the
hand
and technique should be used to best assess the patients skin temperature?
a. Fingertips; they are more sensitive to small changes in temperature.
b. Dorsal surface of the hand; the skin is thinner on this surface than on the
palms.
c. Ulnar portion of the hand; increased blood supply in this area enhances
temperature sens
Palmar surface of the hand; this surface is the most sensitive to
temperature variations b
, d. of its increased nerve supply in this area.
ANS:
B
The dorsa (backs) of the hands and fingers are best for determining temperature
because the skin is thinner on the dorsal surfaces than on the palms.
Fingertips are best for fine, tactile discrimination. The other
responses are not useful for palpation.
, 4. Which of these techniques uses the sense of touch to assess texture,
temperature,
moisture, and swelling when the nurse is assessing a patient?
a.
d. Auscultation
ANS: A
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.
5. The nurse is preparing to assess a patients abdomen by palpation. How should
the
nurse proceed?
Palpation of reportedly tender areas are avoided because palpation in
these areas may ca
a. pain.
Palpating a tender area is quickly performed to avoid any discomfort that
the patient ma
b. experience.
The assessment begins with deep palpation, while encouraging the patient
to relax and to
c. deep breaths.
The assessment begins with light palpation to detect surface
characteristics and to accust
d. patient to being touched.
ANS:
D
Light palpation is initially performed to detect any surface
characteristics and to accustom the person to being touched. Tender
areas should be palpated last, not first.
6. The nurse would use bimanual palpation technique in which situation?
a. Palpating the thorax of an infant
b. Palpating the kidneys and uterus
c. Assessing pulsations and vibrations
