chap 3

Question 1

objective data

Answer 1

nurse directly observes it

Question 2

nurse needs basic knowledge of

Answer 2

• types/operation of equipment needed
• prep of setting, oneself, and client
• performance of 4 assessment techniques

Question 3

4 assessment techniques

Answer 3

• inspection
• palpation
• percussion
• auscultation

Question 4

physical exam prep

Answer 4

• comfortable, warm temp
• private area free from interruptions
• quiet area free of distractions
• adequate lighting
• firm exam table
• bedside table/tray

Question 5

standard precautions

Answer 5

used in care of all patients regardless of their diagnosis/infection
-combines universal and body substance precautions

Question 6

standard precautions guidelines

Answer 6

• wash hands before exam
• wash hands immediately after direct contact w/ blood
• always wear gloves if chance of contact w/ blood/body fluids
• change gloves between pt’s

Question 7

most important reason for wearing gloves

Answer 7

prevent nurse’s hands from being a vehicle of transmission from one pt to another

Question 8

client approach/prep

Answer 8

• est. nurse pt relationship
• respect client’s requests/desires
• leave room while pt changes
• provide necessary container
• begin exam w/ less intrusive
• explain procedure
• explain why position change is necessary

Question 9

inspection

Answer 9

• using senses to observe normal/abnormal findings
• room temp is comfortable
• good lighting
• LOOK before TOUCH
• note characteristics
• compare appearance

Question 10

note the following characteristics when inspecting

Answer 10

• color
• pattern
• size
• location
• consistency
• symmetry
• movement
• behavior
• odors
• sounds

Question 11

what to look for when palpating

Answer 11

• texture (rough/smooth)
• temp
• moisture (dry/wet)
• mobility (fixed/movable/still/vibrating)
• consistency (soft/hard/fluid filled)
• strength of pulse (strong/weak/bounding/thready)
• size
• shape (well defined/irregular)
• degree of tenderness

Question 12

types of palpation

Answer 12

• light
• moderate
• deep
• bimanual

Question 13

light palpation

Answer 13

• place dominant hand lightly on surface of structure
• very little to no depression
• feel surface using a circular motion
• feel for pulses, tenderness, surface skin texture, moisture

Question 14

moderate palpation

Answer 14

• depress skin surface 1-2 cm with dominant hand

- note size, consistency, and mobility of structures

Question 15

deep palpation

Answer 15

• place dominant hand on skin surface and non-dominant hand to apply pressure
• depression 2.5-5 cm
• allows to feel deep organs/structures covered by thick muscle

Question 16

bimanual palpation

Answer 16

requires use of both hands to envelop/capture body parts/organs

Question 17

percussion

Answer 17

involves tapping body part to produce sound waves to assess structures

Question 18

purposes of percussion

Answer 18

• eliciting pain: helps detect inflamed underlying structure
• determining location, size, shape
• detecting abnormal masses
• eliciting reflexes: deep tendon reflexes elicited using percussion hammer

Question 19

types of percussion

Answer 19

direct, blunt, indirect/mediate

Question 20

direct percussion

Answer 20

direct tapping to elicit possible tenderness

Question 21

blunt percussion

Answer 21

used to detect tenderness over organs

Question 22

indirect/mediate percussion

Answer 22

MOST COMMON, sound varies w/ density

Question 23

sounds elicited by percussion

Answer 23

• resonance
• hyperresonance
• tympany
• dullness
• flatness

Question 24

as density increases sound becomes

Answer 24

quieter

Question 25

auscultation

Answer 25

listening with a stethoscope

Question 26

tips for auscultation

Answer 26

• eliminate distracting noise
• expose the body part being auscultated
• diaphragm of stethoscope = high pitched sounds
• bell of stethoscope = low pitched sounds

Question 27

correct use of stethoscope

Answer 27

• place earpieces into outer ear canal
• angle binaurals down toward nose
• warm diaphragm/bell before use
• explain what you are listening to/answer questions
• avoid listening through clothes
• clean stethoscope