Physical assesments

During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which of these statements by the nurse is most appropriate?

ANS: "Your pulse is 80 beats per minute. This is within the normal range." Sharing of some information builds rapport as long as the patient is able to understand the terminology.

When examining an infant, the nurse should examine which area first?

ANS: Abdomen Perform the least distressing steps first. Save the invasive steps of examination of the eye, ear, nose, and throat until last.

A 2-year-old child has been brought to the clinic for a well-child check-up. The best way for the nurse to begin the assessment is reflected by which statement?

ANS: Allow the child to keep a security object such as a toy or blanket during the examination. The best place to examine the toddler is on the parent's lap. Toddlers understand symbols, so a security object is helpful. Initially, focus more on the parent. This allows the child to gradually adjust and become familiar with you. A 2-year-old child does not like to take off his or her clothes. Have the parent undress one body part at a time.

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?

ANS: Appear unhurried and confident when examining him. 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 examining an aging adult, the nurse should use which technique?

ANS: Arrange the sequence to allow as few position changes as possible. When examining the aging adult, it is best to arrange the sequence of the examination to allow as few position changes as possible. Physical touch is especially important with the aging person because other senses may be diminished.

During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?

ANS: Ask another nurse to double-check the finding. If an abnormal finding is not familiar, then the nurse may ask another examiner to double-check the finding. The other responses do not help to identify the unfamiliar sound.

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?

ANS: At the end of the examination Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry.

A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination?

ANS: Auscultate the lungs and heart while the infant is still sleeping. When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination.

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

ANS: Palpation Palpation applies the sense of touch to assess these factors: 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 presence of tenderness or pain.

The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of the nurse's technique is most accurate?

ANS: Children at this age like to say "No." The examiner should not offer a choice when there is none. Children at this age like to say "No." Do not offer a choice when there really is none. If the child says "No," and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, "Shall I listen to your heart next or your tummy?"

The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4-year-old child. What should the nurse do next?

ANS: Consider this a normal finding for a child this age and proceed with the examination. Percussion notes that are louder in amplitude, lower in pitch, of a booming quality, and longer in duration are normal over a child's lung.

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

ANS: Examine body areas appropriate to the problem and then complete the assessment after the problem has resolved. It may be necessary in this situation to alter the position of the patient during the examination and to collect a mini data base by examining the body areas appropriate to the problem. You may return later to complete the assessment after the distress is resolved.

The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group?

ANS: Give the child feedback and reassurance during the examination. With preschool children use short, simple explanations. Children at this age are usually willing to undress. Examination of the head should be performed last. During the examination give the preschooler needed feedback and reassurance.

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?

ANS: Increase the amount of strength used when attempting to percuss over the abdomen. The thickness of the person's body wall will be a factor. The nurse will need 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.

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

ANS: Palpation 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 perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?

ANS: Inspection takes time and reveals a surprising amount of information. 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 much more than a "quick glance."

The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?

ANS: Keep in mind that a child this age will have a sense of modesty. A 6-year-old child has a sense of modesty. The child should undress himself or herself, leaving underpants on, and use a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from head to toes.

The nurse would use bimanual palpation technique in which situation?

ANS: Palpating the kidneys and uterus 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.

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After putting a call in to the physician and placing the patient on oxygen, which of these is the best action for the nurse to take when assessing the patient further?

ANS: Percuss the thorax bilaterally, noting any differences in percussion tones. Percussion is always available, portable, and gives instant feedback regarding changes in underlying tissue density, which may yield clues of the patient's physical status.

With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as, having the patient "blow out" the light on the penlight?

ANS: Preschool child When assessing preschool children, it is helpful to use games or allow them to play with the equipment to reduce their fears. Such games are not appropriate for the other age groups listed.

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 performed correctly?

ANS: Rotating the lens selector dial to bring the object into focus 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.

Which of these statements is true regarding the use of standard precautions in the health care setting?

ANS: Standard precautions are intended for use with all patients regardless of their risk or presumed infection status. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources. They are intended for use for all patients, regardless of their risk or presumed infection status. They apply to blood and all other body fluids, secretions and excretions except sweat—regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids; alcohol-based hand rubs can be used if hands are not visibly soiled.

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?

ANS: Start with light palpation to detect surface characteristics and to accustom the patient to being touched. Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.

While auscultating heart sounds, the nurse hears a murmur. Which of these should be used to assess this murmur?

ANS: The bell of the stethoscope The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds.

The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?

ANS: The stethoscope does not magnify sound but does block out extraneous room noise. The stethoscope does not magnify sound but does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner's nose. Longer tubing will distort sound. The fit and quality of the stethoscope are important.

During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sound across the quadrants. This type of sound indicates:

ANS: air-filled areas. A musical or drum-like sound (tympany) is the sound heard when percussion occurs over an air-filled viscus, such as the stomach or intestines.

The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes correct technique for this procedure? Select all that apply.

ANS: Warm the hands first before touching the patient., Start with light palpation to detect surface characteristics., Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps., Identify any tender areas, and palpate them last. Always warm the hands before beginning palpation. Use intermittent pressure rather than one long continuous palpation; identify any tender areas, and palpate them last. Fingertips are used to examine skin texture, swelling, pulsation, and presence of lumps. Use the dorsa (backs) of the hands to assess skin temperature because the skin on the dorsa is thinner than on the palms.

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?

ANS: Wash hands before and after every physical patient encounter. 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 there is potential contact with any body fluids.

The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation?

ANS: Wash hands, put on gloves, and continue with the examination of the ulceration. The examiner should wear gloves when there is potential contact with any body fluids. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration.

The nurse keeps in mind that the most important reason to share information and offer brief teaching while performing the physical examination is to help:

ANS: build rapport and increase the patient's confidence in the examiner. Sharing of information builds rapport and increases the patient's confidence in the examiner. It also gives the patient a little more control in a situation in which it is easy to feel completely helpless.

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:

ANS: check the temperature of the room and offer blankets to the patient if he or she feels cold. 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.

When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:

ANS: consider this a normal finding. 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 preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the underlying tissue:

ANS: density. 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 preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope:

ANS: directs light into the ear canal and onto the tympanic membrane. 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.

The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the:

ANS: dorsal surface of the hand because the skin is thinner than on the palms. The dorsa (backs) of hands and fingers are best for determining temperature because the skin there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other responses are not useful for palpation.

When preparing to perform a physical examination on an infant, the nurse should:

ANS: have the parent remove all clothing except the diaper on a boy. The parent should always be present to increase the child's feeling of security and to understand normal growth and development. Timing of the examination should be 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants do not object to being nude; clothing should be removed but a diaper should be left on a boy.

When performing a physical assessment, the technique the nurse will always use first is:

ANS: inspection. 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, where 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 use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm:

ANS: is used to listen for high-pitched sounds. The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be held firmly 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.

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:

ANS: organizes the assessment so that the patient does not change positions too often. The steps of the assessment should be organized so 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.

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? The nurse:

ANS: percusses once over each area. For percussion, the nurse should percuss two times over each location. The striking finger should be lifted off quickly 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 it is used to make the strikes, not the arm.

When examining a 16-year-old male teenager, the nurse should:

ANS: provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development. During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body image and often compares himself or herself to peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development.

The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:

ANS: use a Doppler device to check for pulsations over the area. 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 most important step that the nurse can take to prevent transmission of microorganisms in the hospital setting is to:

ANS: wash hands before and after contact with each patient. The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed.