HA Chapter 8: Assessment Techniques - Set 2

In infants, the nurse knows to elicit the Moro reflex: 1.when the infant is sleeping. 2.at the end of the examination. 3.before auscultation of the thorax. 4.halfway through the examination.

ANS: 2 Elicit the Moro or "startle" reflex at the end of the examination because it may cause the baby to cry.

The nurse is preparing to palpate the thorax and abdomen of a patient. For each description listed below, specify the appropriate part of the hand that should be used for palpation. 1.Should be used to detect the shape and consistency of a mass in the axilla 2.Best for evaluating the skin texture over the abdomen. 3.Used to determine the temperature of the patient's skin. 4.Best for detecting vibration over the thorax and abdomen.

1. A grasping action of the fingers and thumb 2. Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand 3. Fingertips 4. The dorsa (backs) of hands and fingers 1. ANS: 1 2. ANS: 3 3. ANS: 4 4. ANS: 2

The nurse would use bimanual palpation technique in which situation? 1.Palpating the thorax of an infant 2.Palpating the kidneys and uterus 3.Assessing pulsations and vibrations 4.Assessing the presence of tenderness and pain

2. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa.

A man is at the clinic for a physical examination. He states that he is "very anxious" about the physical exam. What steps can the examiner take to make him more comfortable? 1.Appear unhurried and confident when examining him. 2.Stay in the room when he undresses in case he needs assistance. 3.Ask him to change into an examining gown and take off his undergarments. 4.Defer measuring vital signs until the end of the examination, which allows him. time to become comfortable.

ANS: 1 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.

Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations? 1.Palpation 2.Inspection 3.Percussion 4.Auscultation

ANS: 1 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.

Which of the following techniques uses the sense of touch when assessing a patient? 1.Palpation 2.Inspection 3.Percussion 4.Auscultation

ANS: 1 Palpation uses the sense of touch to assess the patient.

When percussing over the ribs of a patient, the nurse notes a dull sound. The nurse would: 1.consider this a normal finding. 2.palpate this area for an underlying mass. 3.reposition the hands and attempt to percuss in this area again. 4.consider this an abnormal finding and refer the patient for additional treatment.

ANS: 1 Percussion over bones or large muscles will produce a dull sound.

Which statement is true regarding the diaphragm of the stethoscope? 1.Use the diaphragm to listen for high-pitched sounds. 2.Use the diaphragm to listen for low-pitched sounds. 3.Hold the diaphragm lightly against the person's skin to block out low-pitched sounds. 4.Hold the diaphragm lightly against the person's skin to listen for extra heart sounds and murmurs.

ANS: 1 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.

When preparing to perform a physical examination on an infant, the examiner should: 1.have the parent remove all clothing except the diaper on a boy. 2.instruct the parent to feed the infant immediately before the exam. 3.encourage the infant to suck on a pacifier during the abdominal exam. 4.ask the parent to briefly leave the room when assessing the infant's vital signs.

ANS: 1 The parent should always be present for 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 not too drowsy nor too hungry. Infants do not object to being nude; clothing should be removed and a diaper left on a boy.

A 6-month-old infant has been brought to the well-child clinic for a check up. She is currently sleeping. What should the examiner do first? 1.Auscultate the lungs and heart while the infant is still sleeping. 2.Examine the infant's hips because this procedure is uncomfortable. 3.Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. 4.Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.

ANS: 1 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 inspection phase of the physical assessment: 1.yields little information. 2.takes time and reveals a surprising amount of information. 3.may be somewhat uncomfortable for the expert practitioner. 4.requires a quick glance at the patient's body systems before proceeding on with palpation.

ANS: 2 A focused inspection takes time and yields a surprising amount of data. Initially, the examiner may feel uncomfortable "staring" at the person without also "doing something."

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: 1.constipation. 2.air-filled areas. 3.the presence of a tumor. 4.the presence of dense organs.

ANS: 2 A musical or drum-like sound (tympany) is the sound heard when percussion occurs over air-filled viscus, such as the stomach or intestines.

The nurse is preparing to percuss the thorax of an adult. Which technique is correct? 1.Use the direct percussion technique. 2.Use the indirect percussion technique. 3.Use the ulnar surface of the hand to percuss the thorax. 4.Use the dorsal surface of the hand to percuss the thorax.

ANS: 2 Indirect percussion. With indirect percussion, the striking hand contacts the stationary hand fixed on the person's skin. This technique is used most often.

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take? 1.Count the respirations and put a call in to the physician. 2.Percuss the thorax bilaterally, noting any differences in percussion tones. 3.Call for a chest x-ray and wait for the results before beginning an assessment. 4.Inspect the thorax for any new masses and bleeding associated with respirations

ANS: 2 Percussion is always available, portable, and gives instant feedback regarding changes in underlying tissue density.

The most important reason to share information and offer brief teaching while performing the physical examination is to help: 1.the examiner feel more comfortable and gain control of the situation. 2.build rapport and increase the patient's confidence in the examiner. 3.the patient understand his or her disease process and treatment modalities. 4.the patient identify questions about his or her disease and potential areas of patient education.

ANS: 2 Sharing of information builds rapport and increases the patient's confidence in you as an examiner. It also gives the patient a little more control in a situation in which it's easy to feel completely helpless.

When performing a physical assessment, the technique the nurse will always use first is: 1.palpation. 2.inspection. 3.percussion. 4.auscultation.

ANS: 2 The assessment of each body system begins with inspection.

While auscultating heart sounds, the nurse hears a murmur. Which of the following should be used to assess this murmur? 1.An electrocardiogram 2.The bell of the stethoscope 3.The diaphragm of the stethoscope 4.Palpation with the palm of one's hand

ANS: 2 The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs.

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? 1.Use the fingertips because they're more sensitive to small changes in temperature. 2.Use the dorsal surface of the hand because the skin is thinner than on the palms. 3.Use the ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. 4.Use the palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.

ANS: 2 The dorsa (backs) of hands and fingers are best for determining temperature because the skin there 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 the following statements describes the most appropriate actions the examiner should take when performing a physical examination? 1.There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. 2.Wash hands at the beginning of the examination and any time that one leaves and re-enters the room. 3.Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. 4.Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

ANS: 2 The examiner should wash his or her hands at the beginning of the examination and each time he or she re-enters the room. Gloves should be worn when there is potential contact with any body fluids. Hands should be washed after gloves have been removed, even if the gloves appear to be intact.

Which of the following statements is true regarding the stethoscope and its use? 1.The slope of the earpieces should point posteriorly (toward the occiput). 2.The stethoscope does not magnify sound but does block out extraneous room noise. 3.The fit and quality of the stethoscope are not as important as its ability to magnify sound. 4.The ideal tubing length should be 22 inches long to dampen distortion of sound.

ANS: 2 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.

With which of the following patients would it be most appropriate to use games during the assessment, such as, having the patient "blow out" the light on the penlight? 1.An infant 2.A preschool child 3.A school-age child 4.An adolescent

ANS: 2 When assessing preschool children, it is helpful to use games or allow them to play with the equipment to reduce their fears.

The nurse is preparing to examine a 4-year-old child. Which action is appropriate first? 1.Explain procedures in detail to alleviate the child's anxiety. 2.Give the child feedback and reassurance during the examination. 3.Do not ask the child to remove his clothes because children at this age are usually very private. 4.Perform an examination of the ear, nose, and throat first and then examine the thorax and abdomen.

ANS: 2 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.

When preparing to examine a 6-year-old child, which action is most appropriate? 1.Start with the thorax, abdomen, and genitalia before examining the head. 2.Avoid talking about the equipment being used because it may increase the child's anxiety. 3.Keep in mind that a child this age will have a sense of modesty. 4.Have the child undress from the waist up.

ANS: 3 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 is unable to palpate the right radial pulse on a patient. The best action would be to: 1.auscultate over the area with a fetoscope. 2.use a goniometer to measure the pulsations. 3.use a Doppler device to check for pulsations over the area. 4.check for the presence of pulsations with a stethoscope.

ANS: 3 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 nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? 1.Ask the patient to take deep breaths to relax the abdominal musculature 2.Consider this a normal finding and proceed with the abdominal assessment. 3.Increase the amount of strength used when attempting to percuss over the ab- domen. 4.Decrease the amount of strength used when attempting to percuss over the abdomen.

ANS: 3 Percuss two times in this location using even, staccato blows. Lift the striking finger off quickly; a resting finger damps off vibrations. The thickness of the person's body wall will be a factor. You 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 nurse is preparing to percuss to assess the underlying: 1.tissue turgor. 2.tissue texture. 3.tissue density. 4.tissue consistency.

ANS: 3 Percussion yields a sound that depicts the location, size, and density of the underlying organ.

During the examination, it is often appropriate to offer some brief teaching about the patient's body or one's findings. Which of the following statements by the nurse is most appropriate? 1."Your hypertension is under control." 2."You have pitting edema and mild varicosities." 3."Your pulse is 80 beats per minute. This is within the normal range." 4."I'm using my stethoscope to listen for any crackles, wheezes, or rubs."

ANS: 3 Sharing of information builds rapport as long as the patient is able to understand the terminology.

A 2-year-old child has been brought to the clinic for a well-child check-up. How should the examiner proceed with the assessment? 1.Ask the parent to place the child on the examining table. 2.Have the parent remove all the child's clothing before the examination. 3.Allow the child to keep a security object such as a toy or blanket during the examination. 4.Initially focus interactions on the child, essentially "ignoring" the parent, until the child's trust has been obtained.

ANS: 3 Sitting on the parent's lap is the best place to examine the toddler. 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 does not like to take off his or her clothes. Have the parent undress one body part at a time.

Which of the following statements is true regarding the use of standard precautions in the healthcare setting? 1.Standard precautions apply to all body fluids, including sweat. 2.Airborne, droplet, and contact transmission-based precautions are included in the use of standard precautions. 3.Standard precautions are intended for use with all patients regardless of their risk or presumed infection status. 4.Standard precautions are to be used only when there is nonintact skin, excretions contain visible blood, or contact with mucous membranes is expected.

ANS: 3 Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources. They apply to blood and all other body fluids, secretions and excretions except sweat—regardless of whether they contain visible blood, nonintact skin, and/or mucous membranes.

The nurse is examining a patient's lower leg and notes a draining ulceration. Which of the following actions is most appropriate in this situation? 1.Wash hands and contact the physician. 2.Continue to examine the ulceration and then wash hands. 3.Wash hands, put on gloves, and continue with the examination of the ulceration. 4.Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration.

ANS: 3 The examiner should wear gloves when there is potential contact with any body fluids. In this situation, you should wash your hands, put on gloves, and continue examining the ulceration.

The most important step that the nurse can take to prevent transmission of nosocomial infections in the hospital setting is to: 1.wear protective eye wear at all times. 2.wear gloves during any and all contact with patients. 3.wash hands before and after contact with each patient. 4.clean the stethoscope with an alcohol swab between patients.

ANS: 3 The most important step to decrease the risk of microorganism transmission is to wash your hands promptly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab between patients.

The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of her technique is most accurate? 1.Asking questions enhances the child's autonomy. 2.Asking the child for permission helps to develop a sense of trust. 3.This is an appropriate statement because children at this age like to have choices. 4.Children at this age like to say "No." The examiner should not offer a choice when there is none.

ANS: 4 Children at this age like to say "No." Do not offer a choice when there really is none. If the child says "No," and you go ahead and do it anyway, you lose trust. Autonomy is enhanced by offering a limited option, "Shall I listen to your heart next or your tummy?"

When examining a 16-year-old male teenager, the examiner should: 1.discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. 2.ask his parent to stay in the room during the history and physical examination to answer any questions and alleviate his anxiety. 3.talk to him the same as one would talk would a younger child because a teen's level of understanding may not match his or her speech. 4.provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.

ANS: 4 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, often comparing himself or herself to peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development.

During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next? 1.Document the findings in the patient's record. 2.Wait 10 minutes and auscultate the sound again. 3.Ask how the patient is feeling. 4.Ask another nurse to double-check the finding.

ANS: 4 If an abnormal finding is not familiar, the nurse may ask another examiner to double-check the finding.

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? 1.Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment. 2.Obtain a thorough history and physical assessment information from the patient's family member. 3.Perform a complete history and physical assessment immediately to obtain baseline information. 4.Examine body areas appropriate to the problem and then complete the assessment after the problem has resolved.

ANS: 4 It may be necessary in this situation to alter the position of the patient during the examination and to collect a mini database 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 assess a patient's abdomen by palpation. How should the nurse proceed? 1.Avoid palpation of reported "tender" areas because this may cause the patient pain. 2.Quickly palpate the area to avoid any discomfort that the patient may experience. 3.Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. 4.Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

ANS: 4 Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched.

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? 1.Palpate over the area for increased pain and tenderness. 2.Ask the child to take shallow breaths and percuss over the area again. 3.Refer the child immediately because of an increased amount of air in the lungs. 4.Consider this a normal finding for a child this age and proceed with the examination.

ANS: 4 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.

When examining an infant, the nurse should examine which area first? 1.Ear 2.Nose 3.Throat 4.Abdomen

ANS: 4 Perform the least distressing steps first. Save the invasive steps of examination of the eye, ear, nose, and throat until last.

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse will: 1.warm the end piece of the stethoscope by placing it in warm water. 2.leave the gown on so that the patient does not get chilled during the examination. 3.make sure that the bell side of the stethoscope is turned to the "on" position. 4.check the temperature of the room and offer blankets to the patient if he or she feels cold.

ANS: 4 The examination room should be warm. If the patient shivers, 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. Never listen through a gown. The diaphragm of the stethoscope would be used to auscultate for bowel sounds.

An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of the following techniques would indicate the examination is being performed correctly? 1.Using the large full circle of light when assessing pupils that are not dilated 2.Rotating the lens selector dial to the black numbers to compensate for astigmatism 3.Using the grid on the lens aperture dial to visualize the external structures of the eye 4.Rotating the lens selector dial to the red numbers to compensate for nearsightedness

ANS: 4 The ophthalmoscope is used to examine the internal eye structures. It can compen- sate for nearsightedness or farsightedness, but it will not correct for astigmatism. The red numbers indicate a negative lens and can compensate for myopia. 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.

Which of the following statements is true regarding the otoscope? 1.The otoscope is often used to direct light onto the sinuses. 2.The otoscope uses a short broad speculum to visualize the ear. 3.The otoscope is used to examine the structures of the internal ear. 4.The otoscope directs light into the ear canal and onto the tympanic membrane.

ANS: 4 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.

When performing the physical assessment, the examiner should: 1.perform the examination from the left side of the bed. 2.examine tender or painful areas first to help relieve the patient's anxiety. 3.follow the same examination sequence regardless of the patient's age or condition. 4.organize the assessment so that the patient does not change positions too often.

ANS: 4 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 steps of the assessment should be organized so that the patient does not change positions too often.

When examining the aging adult, the nurse should: 1.avoid touching the patient too much. 2.attempt to perform the entire physical during one visit. 3.speak loudly and slowly because most aging adults have hearing deficits. 4.arrange the sequence to allow as few position changes as possible.

ANS: 4 When examining the aging adult, it is best to arrange the sequence of the examina- tion to allow as few position changes as possible. Physical touch is especially important with the aging person because other senses may be diminished.