Chapter 8: Assessment techniques (palpation)

Question 1

Order of physical assessment

Answer 1

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).

Question 2

Focused Inspection

inspection phase

Answer 2

takes time and yields a surprising amount of information.

Question 3

focused assessment

Answer 3

is significantly more than a “quick glance

Question 4

best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms

Answer 4

dorsa (backs) of the hands and fingers

Question 5

best for fine, tactile discrimination

Answer 5

Fingertips

Question 6

Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient

Answer 6

palpation

Question 7

what involves vision

Answer 7

inspection

Question 8

assesses through the use of palpable vibrations and audible sounds

Answer 8

percussion

Question 9

what uses the sense of hearing.

Answer 9

auscultation

Question 10

initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.

Answer 10

Light palpation

Question 11

use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa

Answer 11

Bimanual palpation

Question 12

what yields a sound that depicts the location, size, and density of the underlying organ

Answer 12

Percussion

Question 13

Turgor and texture are assessed with?

Answer 13

palpation

Question 14

percussion,

Answer 14

the nurse should percuss two times over each location

Question 15

percussion

Answer 15

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.

Question 16

Percussion over relatively dense organs, such as the liver or spleen makes what sound

Answer 16

dull

Question 17

requires good lighting, adequate exposure, and occasional use of certain instruments (otoscope, ophthalmoscope, penlight, nasal and vaginal specula) to enlarge your view

Answer 17

Inspection

Question 18

what assess texture; temperature; moisture; organ location and size; and any swelling, vibration or pulsation, rigidity or spasticity (muscle tightness), crepitation, presence of lumps or masses, and presence of tenderness or pain.

Answer 18

Palpation

Question 19

what part of arm Best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps

Answer 19

fingertips

Question 20

what detects the position, shape, and consistency of an organ or mass

Answer 20

grasping action of the fingers and thumb

Question 21

whats best detecting vibration

Answer 21

Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand

Question 22

deep palpation

Answer 22

(as for abdominal contents), intermittent pressure is better than one long, continuous palpation.

Question 23

Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors

Answer 23

percussion

Question 24

Signaling the density (air, fluid, or solid) of a structure by a characteristic note

Answer 24

percussiion

Question 25

Detecting an abnormal mass if it is fairly superficial; the percussion vibrations penetrate about 5 cm (2 inches) deep

Answer 25

percussion

Question 26

Eliciting a deep tendon reflex

Answer 26

using percussion hammer

Question 27

Hyperextend the middle finger (the pleximeter) and place its distal joint and tip firmly against the person’s skin. Avoid placement over the ribs, scapulae, and other bony prominences.
-direct percussion- involves tapping lightly with pad of finger directly on clients skin

Answer 27

Stationary Hand (method of percussion)

Question 28

the goal is to hit the portion of the finger that is pushing the hardest into the skin surface
Use the middle finger of your dominant hand as the striking finger (the plexor) (Fig. 8.3). Hold your forearm close to the skin surface, with your upper arm and shoulder steady.
-indirect percussion (use both hands) strike stationary finger like hammer to produce best sound
Flex the striking finger so that its tip, not the finger pad, makes contact. It hits directly at right angles to the stationary finger.

Answer 28

Striking Hand (method of percussion)

Question 29

(1) amplitude (or intensity), a loud or soft sound;
(2) pitch (or frequency), the number of vibrations per second;
(3) quality (timbre), a subjective difference caused by the distinctive overtones of a sound;
(4) duration, the length of time the note lingers.

Answer 29

Percussion vibrations produce waves aka notes

Question 30

(1) amplitude (or intensity)- medium-loud
(2) pitch (or frequency)- low
(3) quality (timbre)- clear,hollow
(4) duration- moderate

Answer 30

Normal lung tissue-Resonant

Question 31

(1) amplitude (or intensity)-Louder
(2) pitch (or frequency)-Lower
(3) quality (timbre)- Booming
(4) duration- Longer

Answer 31

Hyperresonant
Normal over child’s lung
Abnormal in the adult, over lungs with increased amount of air as in emphysema

Question 32

(1) amplitude (or intensity)-Loud
(2) pitch (or frequency)-High
(3) quality (timbre)- Musical and drumlike (like the kettledrum
(4) duration- Sustained longest

Answer 32

Tympany

Over air-filled viscus (e.g., the stomach, the intestine)

Question 33

(1) amplitude (or intensity)-soft
(2) pitch (or frequency)-high
(3) quality (timbre)- muffled thud
(4) duration- short

Answer 33

Dull

Relatively dense organ as liver or spleen

Question 34

(1) amplitude (or intensity)-very soft
(2) pitch (or frequency)-high
(3) quality (timbre)- A dead stop of sound, absolute dullness
(4) duration- very short

Answer 34

Flat

When no air is present, over thigh muscles or bone or over tumor

Question 35

funnels light into the ear canal and onto the tympanic membrane

Answer 35

Otoscope

Question 36

stethoscope

Answer 36

long tubing distort sound

Question 37

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.

Answer 37

Diaphragm of stethoscope

Question 38

best for soft, low-pitched sounds such as extra heart sounds or murmurs.

Answer 38

Bell of Stethoscope

Question 39

directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear

Answer 39

Otoscope

Question 40

Short, broad speculum

Answer 40

Visualize nares

Question 41

used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism

Answer 41

Opthalmoscope

Question 42

used, most often the small spot for undilated pupils or the large full spot for dilated pupils.

Answer 42

aperture of opthalmoscope

Question 43

Rotating the lens selector dial

Answer 43

brings the object into focus.

Question 44

shows a number, or diopter, that indicates the value of the lens in position. The black numbers indicate a positive lens, from 0 to +40. The red numbers indicate a negative lens, from 0 to −20

Answer 44

lens indicator (Opthalmoscope)

Question 45

measure joint range of motion

Answer 45

goniometer

Question 46

to augment pulse or blood pressure measurement

Answer 46

Doppler sonometer

Question 47

test sensation in the foot, and bladder scanner to assess urine retention.

Answer 47

monofilament

Question 48

used to assess size and location of lesions on the fundus

Answer 48

Grid

Question 49

is used to auscultate fetal heart tones.

Answer 49

fetoscope

Question 50

The sequence of the steps of the assessment may differ, depending on the ?

Answer 50

age of the person and the examiner’s preference

Question 51

elicited at the end of the examination because it may cause the infant to cry.

Answer 51

Moro or startle reflex

Question 52

develops 32 wks gestation
response to sudden lost support
3 components:
1.spreading out arms (abduction)
2.crying
3.pulls arm and leg back in

Answer 52

Moro or startle reflex

Question 53

defines the major task of infancy as establishing trust. An infant is completely dependent on the caregiver for his or her basic needs. If these needs are met promptly and consistently, the infant feels secure and learns to trust others

Answer 53

Erikson (developmental competence)

Question 54

need feedback and reassurance
exam of head should be last
willing to undress (not age 2)

Answer 54

Preschool

Question 55

child has a sense of modesty. The child should undress him or herself, leaving underpants on and using a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from the child’s head to the toes.

Answer 55

6-year old