assessment techniques

Question 1

standard equipment for vital signs

Answer 1

platform scale, stethoscope, sphygmomanometer, thermometer

Question 2

washing in/out

Answer 2

washing in - protects patient from the nurse
washing out - protects nurse from the patient

Question 3

goals for patient positioning

Answer 3

• provide patient comfort and safety
• maintain patient dignity and privacy
• allows maximum visibility and access
  essentially comfort, safety, privacy

Question 4

supine position

Answer 4

face up position

Question 5

fowler’s

Answer 5

sitting up, 30-45 degree angle

Question 6

orthopenic position

Answer 6

AKA tripod position, laying over, helps with shortness of breath

Question 7

prone position

Answer 7

helps oxygenate, face down

Question 8

lateral position

Answer 8

side lying

Question 9

lithotomy position

Answer 9

mainly for surgical or obstetric procedures, “childbirth” position

Question 10

trendelenburg position

Answer 10

head down and feet up (or vice versa)

Question 11

other equipment for physical examination

Answer 11

patient specific
- otoscope, ophthalmoscope, penlight, pocket vision screener

Question 12

types of precautions for PPE (what are you protecting yourself from)

Answer 12

airborne, droplet, contact, contact and enteric, neutropenic precautions/protective isolation

Question 13

airborne precautions

Answer 13

• most contagious
• airborne droplets stay in air for up to 2 hours
• measles, chicken pox, herpes, TB
• needs N95 mask/particulate respirator, gown, gloves, goggles

Question 14

droplet precautions

Answer 14

private room, large drops that go out about 3 feet and fall to floor
- PPE: surgical mask within 3 feet of client, wear gown, goggles, and gloves

Question 15

contact and enteric precautions

Answer 15

private room, diseases with diarrhea, wash hands with soap and water; alcohol does NOT kill these diseases so you have to wash

Question 16

neutropenic precautions

Answer 16

gloves for all procedures, for the immunosuppressed
- no live vaccines, avoid invasive procedures, no live flowers
- no white cell count, immunocompromised

Question 17

donning

Answer 17

• putting on
• ON: gown, mask, goggles, gloves

Question 18

doffing

Answer 18

• taking off
• alphabetical order
• OFF: gloves, goggles, gown, mask

Question 19

standard precautions

Answer 19

• hand hygiene
• wearing appropriate PPE
• how to handle patient equipment
• injection safety practices
• environmental cleaning
• respiratory hygiene/coughing etiquette

Question 20

assessment techniques

Answer 20

inspection, palpation, percussion, auscultation

Question 21

sequence of health assessment

Answer 21

• maximize client’s comfort
• avoid unnecessary changes in position
• enhance clinical efficiency

Question 22

inspection

Answer 22

• close, careful scrutiny
• begins with general survey
• inspection always comes first
• requires good lighting, adequate exposure, occasional use of instruments like otoscope, ophthalmoscope, penlight, nasal and vaginal specula

Question 23

palpation

Answer 23

assesses
- texture, temperature, moisture
- organ location and size
- swelling, vibration, pulsation, or crepitation
- rigidity or spasticity
- presence of lumps or masses
- presence of tenderness or pain

Question 24

bimanual palpation

Answer 24

used only for certain body parts or organs; doctor or provider will do this

Question 25

fingertips (palpation)

Answer 25

best for fine tactile discrimination of skin texture, swelling, pulsation, presence of lumps

Question 26

fingers and thumbs

Answer 26

detection of position, shape, and consistency of an organ or mass

Question 27

dorsa of hands and fingers

Answer 27

best for determining temperature because skin is thinner than on palms

Question 28

base of fingers or ulnar surface of hand

Answer 28

best for vibration

Question 29

percussion

Answer 29

tapping person’s skin with short, sharp strokes to assess underlying structure (bone, air, etc)

Question 30

amplitude (intensity)

Answer 30

loud or soft sound

Question 31

pitch

Answer 31

frequency, number of vibrations per second

Question 32

basic principles of percussion

Answer 32

structure with more air produces louder, deeper sound compared with denser structure

Question 33

diaphragm of stethescope

Answer 33

high pitched sounds

Question 34

bell of stethescope

Answer 34

low pitched sounds

Question 35

ear tips

Answer 35

aim anteriorly, ears toward your patient

Question 36

auscultation

Answer 36

listening to sounds made by arteries, heart, lungs, bowel sounds

Question 37

bruit

Answer 37

swooshing sound in artery

Question 38

murmur

Answer 38

swooshing sound in a heart valve

Question 39

frequency of assessments

Answer 39

depends on patient needs, hospital protocol, purpose of data collection, health care setting, facility standard of care