Chapter 08: Assessment Techniques and Safety in the Clinical Setting Flashcards
- When performing a physical assessment, the first technique the nurse will always use is:
a. Palpation.
b. Inspection.
c. Percussion.
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.
- 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 patient’s 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.”
- The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patient’s 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
sensitivity.
d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because 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.
- Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?
a. Palpation
b. Inspection
c. Percussion
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.
- The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?
a. Palpation of reportedly “tender” areas are avoided because palpation in these areas may
cause pain.
b. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience.
c.The assessment begins with deep palpation, while encouraging the patient to relax and to
take deep breaths.
d. The assessment begins with light palpation to detect surface characteristics and to accustom the 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.
- 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
d. Assessing the presence of tenderness and pain
ANS: B
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 __________ of the underlying tissue.
a. Turgor
b. Texture
c. Density
d. Consistency
ANS: C
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?
a. Percussing once over each area
b. Quickly lifting the striking finger after each stroke
c. Striking with the fingertip, not the finger pad
d. Using the wrist to make the strikes, not the arm
ANS: A
For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted 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 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:
a. Consider this a normal finding.
b. Palpate this area for an underlying mass.
c. Reposition the hands, and attempt to percuss in this area again.
d. Consider this finding as abnormal, and refer the patient for additional treatment.
ANS: A
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?
a. Ask the patient to take deep breaths to relax the abdominal musculature.
b. Consider this finding as normal, and proceed with the abdominal assessment.
c. Increase the amount of strength used when attempting to percuss over the abdomen.
d. Decrease the amount of strength used when attempting to percuss over the abdomen.
ANS: C
The thickness of the person’s body wall will be a factor. The nurse needs 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 loud, long, and low tones when percussing over the lungs of a 4- year-old child. The nurse should:
a. Palpate over the area for increased pain and tenderness.
b. Ask the child to take shallow breaths, and percuss over the area again.
c. Immediately refer the child because of an increased amount of air in the lungs.
d. Consider this finding as normal for a child this age, and proceed with the examination.
ANS: D
Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long 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 calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?
a. Count the patient’s respirations.
b. Bilaterally percuss the thorax, noting any differences in percussion tones.
c. Call for a chest x-ray study, and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations.
ANS: B
Percussion is always available, portable, and offers 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 trueregarding the stethoscope and its use?
a. Slope of the earpieces should point posteriorly (toward the occiput).
b. Although the stethoscope does not magnify sound, it does block out extraneous room noise.
c. Fit and quality of the stethoscope are not as important as its ability to magnify sound.
d. Ideal tubing length should be 22 inches to dampen the distortion of sound.
ANS: B
The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner’s nose. Long tubing will distort sound. The fit and quality of the stethoscope are both important.
- The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm:
a. Is used to listen for high-pitched sounds.
b. Is used to listen for low-pitched sounds.
c. Should be lightly held against the person’s skin to block out low-pitched sounds.
Should be lightly held against the person’s skin to listen for extra heart sounds and
d. murmurs.
ANS: A
The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be firmly held 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:
a. Warm the endpiece of the stethoscope by placing it in warm water.
b.Leave the gown on the patient to ensure that he or she does not get chilled during the
examination.
c. Ensure that the bell side of the stethoscope is turned to the “on” position.
d. Check the temperature of the room, and offer blankets to the patient if he or she feels cold.
ANS: D
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?
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
ANS: A
Palpation applies the sense of touch to assess 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 the presence of tenderness or pain.
- The nurse is preparing to use an otoscope for an examination. Which statement is trueregarding the otoscope? The otoscope:
a. Is often used to direct light onto the sinuses.
b. Uses a short, broad speculum to help visualize the ear.
c. Is used to examine the structures of the internal ear.
d. Directs light into the ear canal and onto the tympanic membrane.
ANS: D
The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. A short, broad speculum is used to visualize the nares.
- An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed?
a. Using the large full circle of light when assessing pupils that are not dilated
b. Rotating the lens selector dial to the black numbers to compensate for astigmatism
c. Using the grid on the lens aperture dial to visualize the external structures of the eye
d. Rotating the lens selector dial to bring the object into focus
ANS: D
The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus.
- The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
a. Auscultate over the area with a fetoscope.
b. Use a goniometer to measure the pulsations.
c. Use a Doppler device to check for pulsations over the area.
d. Check for the presence of pulsations with a stethoscope.
ANS: C
Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.
- The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:
a. Performs the examination from the left side of the bed.
b. Examines tender or painful areas first to help relieve the patient’s anxiety.
c. Follows the same examination sequence, regardless of the patient’s age or condition.
d. Organizes the assessment to ensure that the patient does not change positions too often.
ANS: D
The steps of the assessment should be organized to ensure that the patient does not change positions too often. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiner’s preference. Tender or painful areas should be assessed last.
- A man is at the clinic for a physical examination. He states that he is “very anxious” about the physical examination. What steps can the nurse take to make him more comfortable?
a. Appear unhurried and confident when examining him.
b. Stay in the room when he undresses in case he needs assistance.
c. Ask him to change into an examining gown and to take off his undergarments.
Defer measuring vital signs until the end of the examination, which allows him time to
d. become comfortable.
ANS: A
Anxiety can be reduced by an examiner who is confident, self-assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the person’s vital signs, will gradually accustom the person to the examination.
- When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination?
a. Washing one’s hands after removing gloves is not necessary, as long as the gloves are still
intact.
b. Hands are washed before and after every physical patient encounter.
c. Hands are washed before the examination of each body system to prevent the spread of
bacteria from one part of the body to another.
d. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
ANS: B
The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when potential contact with any body fluids is present.
- The nurse is examining a patient’s lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation?
a. Washing hands, and contacting the physician
b. Continuing to examine the ulceration, and then washing hands
c. Washing hands, putting on gloves, and continuing with the examination of the ulceration
d. Washing hands, proceeding with rest of the physical examination, and then continuing with
the examination of the leg ulceration
ANS: C
The examiner should wear gloves when the potential contact with any body fluids is present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration.
- During the examination, offering some brief teaching about the patient’s body or the examiner’s findings is often appropriate. Which one of these statements by the nurse is most appropriate?
a. “Your atrial dysrhythmias are under control.”
b. “You have pitting edema and mild varicosities.”
c. “Your pulse is 80 beats per minute, which is within the normal range.”
d. “I’m using my stethoscope to listen for any crackles, wheezes, or rubs.”
ANS: C
The sharing of some information builds rapport, as long as the patient is able to understand the terminology.