Assessment Sequence and Techniques

The nurse is performing a thorough examination of a 5-year-old child. When assessing the warmth of the child's skin, the nurse uses which aspect of the hand?

Back surface The back surface of the hand would be used to assess the temperature of the skin.

An 8-year-old is seen in a clinic for a sore throat and cough. The nurse has orders to assess vital signs, auscultate lung sounds, assess the child's weight, and obtain a throat culture. Why would the nurse perform the culture last?

Obtaining a throat culture is uncomfortable The throat culture would be obtained last because it will likely be uncomfortable for the child.

When examining a 15-month-old, which assessment would the nurse perform last?

Otoscopic ear examination The otoscopic ear examination should be reserved for last because it is an invasive, potentially uncomfortable procedure.

Why should the nurse auscultate the abdomen before palpation during an abdominal assessment?

Palpation changes bowel sounds. The nurse would auscultate before palpation, because palpation can cause a shift in intestinal contents and alter bowel sounds.

The nurse is assessing a 2-month-old patient. The nurse conducts which part of the assessment first?

Auscultation of the heart and lungs Auscultation of the heart and lungs should be performed first while the baby is quiet.

The nurse is assessing a 7-year-old. List the body systems in the order in which they would likely be assessed.

Face Neck Chest Genitals Abdomen Extremities

The nurse is performing an assessment on a 3-year-old with a fever and a sore throat. Which part of the hand would the nurse use to palpate cervical lymph nodes?

Fingertips The nurse would use the fingertips to palpate lymph nodes because the fingertips are more sensitive.

The nurse is performing an initial assessment on a 4-year-old child. Before beginning the assessment, what should the nurse do?

Have the child sit beside the parent Having the child sit next to the parent during the examination allows for proper visualization and enlists the parent's help in keeping the child calm and still during the examination.

The nurse is assessing a 4-year-old child with a cough. After noting the child's vital signs, which action would the nurse take?

Inspect the chest Chest inspection is an important assessment and would need to be performed after the child's vital signs have been determined.

The nurse is assessing a patient who reports shortness of breath, wheezing, and chest tightness. Which assessment technique(s) will help the nurse assess the severity of the patient's condition? Select all that apply.

Inspection Inspection is used to visualize the amount of respiratory distress the patient is having. For example, the nurse must determine whether the patient is using accessory muscles to assist with breathing. Auscultation Because auscultation is used to listen to the flow of air through lungs, it can be helpful in determining whether the patient is wheezing and whether airflow is normal; thus it will help the nurse assess the severity of the patient's condition.

Place the steps of the chest examination in the order in which they are performed.

Inspection Palpation Percussion Auscultation

The nurse percusses the chest of a 7-year-old patient with asthma and notes a dull area over the lower left quadrant. How would the nurse describe this finding?

Percussion over a high-density organ or mass Percussion over high-density organs produces a dull sound.