Chapter 9

Question 1

Inspection

Answer 1

Observe patient in a deliberate, systematic manner
Begins the moment the nurse meets the patient, preceding all other skills
Never rushed
Survey appearance and symmetry of patient’s sides
Look at the patient
Listen for natural sounds
Use the sense of smell to detect odors

Question 2

Palpation

Answer 2

Assess patient through the sense of touch
Characteristics: Size, Shape, Location, Mobility
Position

Question 3

Fremitus felt through chest wall

Answer 3

Vibrations felt best through palms
Fremitus: top of chest. Can be done on ulnar side, or with fingertips
Dorsal hand (temp)

Question 4

Light palpation

Answer 4

Light palpation
Begin with this type
Assess surface characteristics, pulse, or a tender location
Light: 1 cm deep

Question 5

Moderate palpation

Answer 5

Moderate palpation
Palmar surface of fingers of dominant hand over structure, rotating in circular motion
Moderate: 1-2 cm deep

Question 6

Deep palpation

Answer 6

2-4 cm deep
For organs that lie deep within a body cavity
Place extended fingers of nondominant hand over fingers of dominant hand for added pressure
Explain to patient what will occur prior to action

Question 7

Indirect Percussion

Answer 7

Most commonly used
Plexor
Hammer or tapping finger
Pleximeter
Device or surface that accepts the tap

Question 8

Direct percussion

Answer 8

Tapping the body with the fingertips of the dominant hand

Question 9

Blunt percussion

Answer 9

Place palm of nondominant hand flat against the surface and strike it with closed-fist dominant hand

Question 10

Tympany

Answer 10

Loud, high-pitched, drumlike tone

Ex: over gastric bubble

Question 11

Resonance

Answer 11

Loud, low-pitched, hollow tone

Lung percussion sound

Question 12

Hyperresonance

Answer 12

Abnormally loud, low tone of longer duration than resonance

COPD. Lungs with a lot of air, or a barrel chest

Question 13

Dullness

Answer 13

High-pitched tone, soft and short

Over organs

Question 14

Flatness

Answer 14

High-pitched tone, very soft and shorter than dullness

Over bone

Question 15

Percussion contd.

Answer 15

Intensity of amplitude: Softness or loudness
Pitch or frequency: Number of vibrations per second
Duration: Length of time
Quality: Recognizable overtones

Question 16

Auscultation

Answer 16

Skill of listening to sounds produced by the body
Requires a quiet environment
Many sounds extremely soft

Question 17

Stethoscope

Answer 17

Auscultates body sounds such as blood pressure, heart sounds, respirations, and bowel sounds
Components: Binaurals (ear piece), Flexible tubing, End piece, Bell, Diaphragm

Question 18

Doppler Ultrasonic Stethoscope

Answer 18

Ultrasonic waves detect sounds that are difficult to hear with a regular stethoscope
Ex: Fetal heart sounds
Eliminate interference with gel on the end of the Doppler probe (transducer)

Question 19

Ophthalmoscope

Answer 19

Inspects internal eye structures

Question 20

Otoscope

Answer 20

Examines external ear structures

Can be used to inspect nose

Question 21

Hand hygiene

Answer 21

Scrub and rinse hands with soap for 40–60 seconds
When hands visibly soiled
After using restroom
After removing gloves
Before and after contact with medical equipment
Nonsterile examination gloves