JENSENS: CHAPTER 3: Physical Examination Techniques and Equipment- Study Questions

List and describe the four techniques of physical assessment.

1. Auscultation is use of the stethoscope to hear movements of air or fluid over the lungs and abdomen. 2. Percussion is making tapping motions with the hands to produce sounds that indicate solid or air-filled spaces over the lungs and other areas. 3. Palpation is use of the hands to feel the firmness of body parts, such as the abdomen. 4.Inspection means observation of the patient for general appearance and any specific details related to the body system, region, or condition under examination.

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a patient. The nurse should be aware of what risk when using this assessment technique? A.Risk for injury B.Risk for infection C.Risk for chronic pain D.Risk for impaired skin integrity

A.Risk for injury

Using the stethoscope to hear movements of air or fluid over the lungs and abdomen ________________________________________

Auscultation

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens? A.Use of alcohol-based hand cleaner B.Respiratory/cough hygiene C.How to recycle personnel protective equipment D.How to clean patient equipment

B.Respiratory/cough hygiene

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs? A.Resonant B.Tympanic C.Hyperresonant D.Flat

C.Hyperresonant

When you observe the patient for general characteristics including age, gender, and level of alertness, what aspect of assessment are you performing? A.Palpating B.Interviewing C.Inspecting D.Auscultating

C.Inspecting

You should use the bell of the stethoscope when auscultating what type of sounds? A.Abnormal sounds B.High-frequency sounds C.Low-frequency sounds D.Sounds that are partially audible without a stethoscope

C.Low-frequency sounds

Light palpation is most appropriate to assess the A.appendix B.bladder C.inflamed areas of skin D.liver

C.inflamed areas of skin

A new graduate nurse is having trouble charting the details of a shift assessment on a patient. The preceptor of the new nurse explains to the nurse that accurate descriptions are essential for A.setting the patient's expectations B.facilitating clear communication C.maximizing the efficiency of care D.legal documentation

D.legal documentation

Observing the patient for general appearance and any specific details related to the body system, region, or condition under examination ________________________________________

Inspection

Using your hands to feel the firmness of body parts, such as the abdomen ________________________________________

Palpation

The nurse has learned that Chris has a latex allergy.

What precautions would Chris's nurse take because of Chris' latex allergy?

Identify in the correct order the five sequential steps of patient-to-patient transmission of pathogens.

A. Organisms are on a patient's skin or immediate environment. B. Organisms are transferred from the patient to the nurse's hands. C. Organisms survive on the nurse's hands for at least several minutes. D. The nurse omits or performs inadequate or inappropriate hand hygiene. E. The nurse's contaminated hands come into direct contact with another patient or environment in direct contact with the patient.

Chris Chow, a 6-year-old boy visiting the clinic today with a fever and "stuffy nose." He came in with his mother who took the day off from work to stay home with him. His temperature is 38.6°C tympanic, pulse 110, respirations 20 breaths/min, and blood pressure 108/66 mm Hg. Chris is generally healthy and is meeting developmental milestones.

Chris is directly admitted to the pediatric floor with a diagnosis of left lower lobe pneumonia. The nurse admitting him is conducting a focused assessment. • What assessment technique would be a priority in Chris's physical assessment? • Why would it be important to teach Chris and his family respiratory/cough etiquette?

Describe respiratory hygiene measures used to reduce the spread of infection.

People with symptoms of a respiratory infection are asked to cover their mouths/noses when coughing or sneezing. As well, they should be encouraged to practice good hand hygiene and to dispose of tissues appropriately.

Making tapping motions with your hands to produce sounds that indicate solid or air-filled spaces over the lungs and other areas ________________________________________

Percussion

Discuss preventative actions for latex allergy

The best preventive action is to avoid contact with latex when possible. Health care facilities can establish latex-free zones for patients and staff. Nurses should take care to avoid carrying any latex substances into such zones, including stethoscopes, urinary catheters, and vials with rubber stoppers. To avoid increasing exposure to latex and, subsequently, allergy rates, institutions are encouraged to substitute powder-free, low-allergen gloves and latex-free gloves for latex gloves when possible.

Describe the intention of standard precautions.

The intention of standard precautions is to prevent disease transmission during contact with non-intact skin, mucous membranes, body substances, and blood-borne contacts (eg, needlestick injury). Because many patients are unaware of being infected, standard precautions serve to help ensure that providers treat all patients equally.

Describe how health care providers can prevent the transmission of pathogens between patients in health care settings.

There are several actions that the nurse can take to address the five steps in the patient-to-patient transmission of microorganisms. These include protecting the hands with gloves, limiting unnecessary contact with patients, and, primarily, practicing vigilant hand hygiene.

Describe what a nurse can do to minimize the adverse effects of repeated hand washing.

To minimize the adverse effects of hand hygiene, nurses can select less irritating products purchased by institutions and use skin moisturizers after washing hands.