Palpation

Question 1

Which of the following is true of light palpation?

A. Light palpation is used to determine involuntary gaurding only
B. During light palpation, the nurse should expect to feel involuntary rigidity
C. Light palpation should examine identified tender areas last to ensure proper deep palpation.

Answer 1

C. Light palpation should examine identified tender areas last to ensure proper deep palpation.

Question 2

If rigidity persists, what type of guarding is the patient displaying?

Answer 2

Involuntary

Question 3

How far do you push down for deep palpation?

Answer 3

5-8 cm (2-3 inches)

Question 4

What doe sthe nurse assess for in deep palpation?

Answer 4

Assess for size, consistency, and location of organs

Question 5

What is the method for deep palpation on obese abdomens?

Answer 5

Bimanual technique
- Place two hands on top of each other
- Top hand does pushing; bottom is relaxed and concentrates on sense of palpation

Question 6

When is mild tenderness normally present?

Answer 6

When palpating the sigmoid colon

Question 7

What must the nurse do if she identifies a mass?

Answer 7

First distinguish from a normally palpable structure or enlarged organ

Question 8

How would the nurse differentiate from air or ascites?

Answer 8

Fluid wave or gas that shifts
- Fluid moves out to flank

Question 9

What sound would air in the abdomen make?

Answer 9

Hyperactive bowel sounds

Question 10

What sound would ascites make?

Answer 10

Shifting
Absent bowel sounds