Chapter 8: Assessment Techniques and Safety in the Clinical Setting

Direct (immediate) percussion method

the striking hand is directly in contact with the body wall

To examine a toddler, the nurse should A. allow the child to sit in the parent's lap B. ask the child to decide whether parents or siblings should be present C. remove the child's clothing at the beginning of the exam D. perform the assessment from head to toes

A. allow the child to sit in the parent's lap Rationale: A toddler doesn't like to take off their clothing, and an older child about 11 or 12 can decide if their parents or siblings can stay in the room during the exam. For a toddler, the nurse should start with nonthreatening areas first and save distressing procedures such as assessment of the head, ears, nose, or throat for last.

The bell of the stethoscope is used: A. for soft, low-pitched sounds B. for high-pitched sounds C. to hold firmly against the skin D. to magnify sound

A. for soft, low pitched sounds Rationale: The bell of the stethoscope is used to detect soft, low pitched/frequency sounds like heart murmurs and bowel sounds. The diaphragm of the stethoscope is used to detect high pitched sounds like breath sounds and normal heart sounds. Both sides of the stethoscope can be held firmly against the skin and they both magnify the sounds heard.

The dorsa of the hands are used to determine A. temperature B. fine tactile discrimination C. position of an organ D. vibration

A. temperature Rationale: The base of the fingers are best for vibrations, a grasping action of the fingers and thumb is the best way to detect position, shape, and consistency of an organ or mass, and the fingertips are best for fine tactile discrimination.

Amplitude is: A. the intensity (soft or loud) of sound. B. the number of vibrations per second C. the length of time the sound lingers D. the subjective difference in a sound's distinctive overtones

A. the intensity (soft or loud) of sound Rationale: Duration is the length of time the sound lingers, pitch is the number of vibrations per second (high or low), and quality is the subjective difference owing to a sounds distinctive overtones.

Skill sequence for abdominal physical assessment

inspection, auscultation, percussion, palpation

4 basic skills of clinical assessment

inspection, palpation, percussion, and auscultation

Fine tactile discrimination is best achieved with the: A. back of the hands and fingers B. fingertips. C. base of the fingers D. opposition of the fingers and thumb

B. fingertips Rationale: The grasping action of the fingers and thumb is used to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for detecting vibration.

The examiner should use handwashing instead of an alcohol-based hand rub: A. if the pt is HIV positive B. if the pt has an infection with C. difficile C. if the pt has an infection with M. tuberculosis D. if the pt has an infection with the hepatitis B virus

B. if the pt has an infection with C. diff Rationale: The examiner should use wash hands when they are visibly soiled and when patients are infected with spore-forming organisms (e.g., C. difficile or Bacillus anthracis). An alcohol-based hand rub would be effective against M. tuberculosis, hepatitis B, and HIV.

For a health assessment, which assessment technique will you use first? A. palpation B. inspection C. percussion D. auscultation

B. inspection Rationale: the sequence of assessment techniques is inspection, palpation, percussion, and auscultation.

When performing percussion, the examiner A. taps fingertips over bony processes B. strikes the stationary finger at the distal interphalangeal joint C. strikes the flank area with the palm of the hand D. strikes the stationary finger at the proximal interphalangeal joint

B. strikes the stationary finger at the distal interphalangeal joint Rationale: This joint is just below the nail bed

The best description of the pitch of a sound wave obtained by percussion is: A. the intensity of the sound B. the number of vibrations per second C. the length of time the note lingers D. the overtones of the note

B. the number of vibrations per second Rationale: The pitch (also called frequency) is defined as the number of vibrations per second. The duration of the sound is the length of time that the sound lingers. The intensity of the sound is defined as the amplitude (how loud or soft it is, and the overtones of the sound are called the quality.

When performing indirect percussion, the stationary finger is struck: A. at the ulnar surface B. at the middle joint C. at the distal interphalangeal joint D. wherever it is in contact with the skin

C. at the distal interphalangeal joint Rationale: The indirect percussion method involves using both hands; one being stationary on the patients skin and the other being the striking hand that strikes the finger at the most distal joint in the finger. For direct percussion one hand is used and the striking hand is in direct contact with the skin being assessed rather than hitting the other hand like indirect.

At the end of the examination, the examiner should A. compare objective and subjective data for discrepancies B. have findings confirmed by another provider C. review the findings with the pt D. complete documentation before leaving the exam room

C. review findings with the patient Rationale: At the end of the examination, the examiner should summarize the findings and share necessary information with the patient. The examiner may take short notes during the examination; complete documentation should occur after leaving the examination room. The examiner should have findings confirmed only if the finding is abnormal and requires confirmation from another examiner. Subjective and objective data should be compared throughout the history and physical examination.

The nurse is performing an assessment of the abdominal region. What is the appropriate sequence for the exam? A. palpation, percussion, inspection, auscultation B. inspection, palpation, auscultation, percussion C. auscultation, percussion, inspection, palpation D. inspection, auscultation, percussion, palpation

D.

The nurse is preparing to do a physical assessment on a pt who is end-stage HIV positive. What should the nurse do for self-protection? A. wash hands, don gloves, gown, and protective face shield B. don gloves and wash hands after exam, no other PPE is necessary C. wash hands and don two pairs of gloves and a gown D. wash hands, don gloves, and wash hands after exam; no other PPE is necessary

D. Rationale: the nurse should always wash hands before and after the exam and the pt should be treated with standard precautions; gloves are necessary with all pts regardless of HIV status

Which of the following is considered when preparing to examine an older adult? A. avoid physical touch to avoid making the older adult uncomfortable B. confusion is a normal, expected finding in an older adult C. be aware that loss will result in poor coping mechanisms D. base the pace of the examination on the patient's needs and abilities

D. base the pace of the examination on the patient's needs and abilities Rationale: The pace of the examination should be adjusted to match the possible slowed pace of the aging person. Use physical touch (if it is not a cultural contraindication) to offset the disadvantages of diminishing vision and hearing. Be aware that loss is inevitable, and adaptation to loss affects health status. Confusion with a sudden onset may signify a disease state and is not a normal process of aging.

Deep palpation is used to A. elicit deep tendon reflexes B. evaluate surface characteristics C. determine the density of a structure D. identity abdominal contents

D. identify abdominal contents Rationale: Light palpation is used to evaluate surface characteristics, percussions with a reflex hammer elicits deep tendon reflexes, and percussion is used to determine the density (air flow through the organ) of a structure by a characteristic note.

An ophthalmoscope examination is an examination of the A. pharynx B. nasal turbinates C. inner ear D. internal structures of the eye

D. internal structures of the eye Rationale: An ophthalmoscope is used for a funduscopic examination, which is an examination of the internal structures of the eye. An otoscope is used to visualize the ear canal and tympanic membrane. A flashlight or penlight and tongue depressor are used to examine the pharynx. An otoscope may also be used with a short, broad speculum to view the nasal turbinates and nares.

To assess a patient's abdomen by palpation, how should the nurse proceed? A. avoid palpation of reported "tender" areas because this may cause the pt pain B. quickly palpate a tender area to avoid any discomfort that the pt may experience C. begin the assessment with deep palpation, encouraging the pt to relax and take deep breaths D. start with light palpation to detect the surface characteristics and to accustom teh pt to being touched

D. start with light palpation to detect the surface characteristics and to accustom teh pt to being touched Rationale: palpation should always begin with light touching to detect the characteristics of the surface of the skin and allow the pt to become comfortable with being touched, then it can proceed into deeper palpation to assess deeper structures.

When inspecting the ear canal of a pt, the examiner chooses which speculum for the otoscope? A. a short, broad one B. the narrowest for the child C. the largest for an adult D. the largest that will fit

D. the largest that will fit Rationale:

During the assessment, which part of the hand is best for detecting vibrations? A. fingertips B. index finger and thumb in opposition C. dorsum of the hand D. ulnar surface of the hand

D. ulnar surface of the hand Rationale: The ulnar surface is best for feeling the vibrations of the skin. The fingertips are best for detecting fine, tactile discrimination of skin structure, swelling, and determining the presence of lumps. The index finger and the thumb in opposition are best for assessing the position, shape, and consistency of an organ or a mass. The dorsum of the hand is best for detecting temperature.

When should we wash our hands to maintain a hygienic environment?

before and after physical contact with each pt, after contact with bodily fluids, after contact with contaminated fluids, and after removing gloves

What do the dorsa (backside) of the hands and fingers assess during palpation?

best for determining temperature because skin here is thinner than on the palms (because they are used more often and are callused)

What do the base of the fingers or the ulnar surface of the hand assess during palpation?

best for feeling vibrations of the skin

What do the fingers and thumb assess during palpation?

detecting position, shape, and consistency of organs or mass

2 types of percussion methods

direct or immediate and indirect or mediate

Bimanual palpation and what organs would you use it on?

feeling the organ between 2 hands; used in cervical exams and breast exams

What do fingertips assess during palpation?

fine tactile discrimination of skin texture, swelling, pulsation, and determining the presence of lumps

Inspection requires

good lighting, adequate exposure (lifting gown to see skin), and occasional use of instruments

Amplitude (intensity) of sound

if it is a loud or soft sound

Duration of sound

length of time that the sound lingers

What should you do before a physical assessment?

make sure the room is quiet and well lit, make sure the pt is comfortable, if there are lots of people make sure they are quiet and ask the pt if they want them there or to wait outside, and ALWAYS take a minute to look around the room when you walk in and inspect the room and pt

Percussion allows us to

map the location and size of organs, signal density, detect a superficial mass, elicit pain if the underlying structure is inflamed, and eliciting a deep tendon reflex using a percussion hammer

Pitch (frequency) of sound

number of vibrations per second

What are some of the instruments used during inspection?

pen light, otoscope, ophthalmoscope, or nasal/vaginal specula to enlarge the view

Palpation should be performed...

slow and systematically; and start with light palpation and if the pt isn't in pain proceed to deep

Basic principles of the product of sounds

structure with more air (lungs) produces a louder, deeper sound compared to a denser structure (like the liver); and vibrations occur in clinical practice based on individual anatomical differences.

Quality (timbre) of sound

subjective differences in sound

Percussion

tapping on a person's skin with short, sharp strokes to assess underlying structures

Palpation senses for

texture (temp and moisture), organ location and size, swelling, vibration, pulsation, rigidity or spasticity, lumps or masses, and tenderness or pain

Indirect (mediate) percussion method

using both hands, the striking hand contacts the stationary hand that is fixed on the person's skin

When should we wear gloves?

when potential for contact with bodily fluids exists, they are not a protective substitute for washing hands, and always wear a gown, mask and PPE when potential exists for blood or fluid splatter