Health Assessment Chapter 3
The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required? otoscope sphygmomanometer stethoscope opthalmoscope
otoscope
The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? pad the table use as a drape collect body fluids serve as a head support
During the examination, one body part should be exposed at a time. The sheet serves as a drape to keep the other body parts covered. The sheet is not used to pad the table, collect body fluids, or to be a head support.
Which of the following techniques are used in a physical assessment? Select all that apply. Inspection Palpation Auscultation Questioning Subjectivity
The four techniques of inspection, palpation, percussion, and auscultation form the basis for physical assessment. Subjectivity and questioning are distracters for this question.
A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? Reflex hammer Tuning fork Tongue depressor Coin or key
The nurse needs a coin or a key to test the client for stereognosis, which is the ability to recognize objects by touch. A reflex hammer is used to determine deep tendon reflexes. A tuning fork is used to test for vibratory sensation. A tongue depressor is used to test for the rise of the uvula and gag
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? Light palpation Moderate palpation Deep palpation Bimanual palpation
The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpations are used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.
What is the principle of percussion? To assess the sound created by the body To strike the abdominal wall with a soft object To create sound over dead spaces in the body To create vibration in a body wall
The principle of percussion is to set the chest wall or abdominal wall into vibration by striking it with a firm object. Options A, B, and C are incorrect because they are not considered the principle of percussion.
The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position? Cervical spine Thorax Axillary nodes Balance
The standing position is used to assess a client's balance in addition to spine range of motion, and visual acuity. The cervical spine and axillary nodes are assessed with the patient in the seated position. The thorax is assessed in either the sitting or lying position.
What can the nurse assess using percussion? Borders of the heart Movement of the diaphragm during expiration Strength of the pulse Rectal distension
Borders of the heart Percussion allows the examiner to assess such normal anatomic details as the borders of the heart. Options B, C, and D are incorrect because they cannot be assessed by percussion.
During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing light palpation. moderate palpation. deep palpation. very deep palpation.
Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.
The nurse is conducting a physical examination of a patient who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position? Range of motion of the spine Posterior chest excursion Head and neck range of motion Dorsiflexion of the foot
Dorsiflexion of the foot Assessment of dorsiflexion can offer information about problems with the cardiovascular and musculoskeletal systems. Dorsiflexion is best assessed when the client is lying down. Spine range of motion is assessed with the patient in the standing position. Posterior chest excursion and head and neck range of motion are assessed with the patient in the sitting position.
A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure? Application of firm pressure when using the bell Using the diaphragm to listen to low-pitched sounds Using the bell to detect high-pitched sounds Ensuring that contact with the skin is maintained
Ensuring that contact with the skin is maintained While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds.
During a comprehensive assessment, the primary technique used by the nurse throughout the examination is palpation. percussion. auscultation. inspection.
Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. This technique is used from the moment that you meet the client and continues throughout the examination. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.
While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using inspection. palpation. Doppler magnification. percussion.
Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.
A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding? Hyper-resonance Resonance Tympany Dullness
Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drumlike sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thudlike sound that is percussed over solid tissue such as the liver.
What is used to gauge central and peripheral nervous system disorders? Strength of a reflex Gait Tuning fork Heat and cold
Strength of a reflex
You should use the bell of the stethoscope when auscultating what type of sounds? Abnormal sounds High-frequency sounds Low-frequency sounds Sounds that are partially audible without a stethoscope
The bell is used with light skin contact to hear low-frequency sounds.
How should the nurse place the ear of an adult when using the otoscope? Up and back Down and back Up and forward Down and forward
When using the otoscope on an adult, the ear should positioned up and back.
What physical assessment technique should a nurse use to obtain a pulse on a client? Light palpation Moderate palpation Deep palpation Bimanual palpation
light palpation The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpation is used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.
The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system? palpation inspection percussion auscultation
Inspection is the only technique that is used when assessing every body part and system. Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds. Palpation, percussion and auscultation are not used to assess every body part or system.
The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? Percuss the region before auscultating. Palpate the region before auscultating. Assist the client to a sitting position. Reduce all environmental noise.
Reduce all environmental noise. Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the patient to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the patient in the lying position.
Which illustrates the nurse using the technique of inspection? The nurse detects a fruity odor of the patient's breath. The nurse notes increased warmth surrounding the patient's incision. The nurse notes a rhythmic lub-dub over the patient's anterior thorax. The nurse detects tympany over the patient's lower abdomen.
Inspection involves conscious observation of the patient's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the patient's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.
During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment? Inspection Palpation Percussion Auscultation
Palpation is the use of tactile pressure from the fingers to assess contours and sizes of organs. Inspection is close observation of the details of a client's appearance, behavior, and movement. Percussion is the use of a finger of one hand to strike a finger of another hand for the purpose of eliciting a tone or sound wave. Auscultation is the use of a stethoscope to heart sounds within the body organs.
A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area? palpation inspection percussion auscultation
Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds.
A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client? Knee-chest Prone Supine Dorsal recumbent
The knee-chest position is useful for examining the rectum. In this position, the client kneels on the examination table with the weight of the body supported by the chest and knees. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the dorsal recumbent position, the client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. Areas that may be assessed with the client in this position include the head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses.
A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique? One to two fingers are placed over the body structure and the fingertips are used to tap the skin surface. The middle finger of one hand is placed on the body surface and the other middle finger strikes. The ulnar surface of one hand is placed against the body surface and vibrations are felt. One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand.
The middle finger of one hand is placed on the body surface and the other middle finger Indirect percussion is the most commonly used of the percussion techniques. This method entails the middle finger of the nondominant hand being placed on the body surface to be assessed. Keeping all other fingers off the body surface, strike this finger with the other middle finger. Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation. Blunt palpation involves placing one hand flat against the body and striking the back of the flat hand with the fist of the other hand.
