223: W4 EAQ

Which statement indicates a correct understanding of the difference between percussion and palpation?

"Percussion is the use of only the fingers to vibrate the underlying tissues and organs, whereas palpation involves the use of different parts of the hand to assess body parts."

Arrange the activities in the correct order for examination of the patient's abdomen.

1. consent from the patient, 2. inspection of abdomen, 3. auscultation of abdomen, 4. palpation of abdomen

Which examination technique is the nurse using when pressing the hand inward about 4 cm (2 inches) into the patient's abdomen?

Deep palpation

While palpating the patient's pulse, the nurse places the fingertips between the first and second toes and slowly moves up the dorsum of the foot. Which pulse is the nurse palpating?

Dorsalis pedis pulse

The nurse is measuring a patient's pulse by directing the patient to lie down. Then the nurse places the fingertips of both hands on the opposite sides of the pulse site. Which pulse is the nurse measuring?

Femoral pulse

Which technique would the nurse use to assess the elasticity of the patient's skin?

By grasping the skin of the forearm with the fingertips and releasing it

The nurse observes excessive dryness in a patient's toenails. The nurse asks which question to determine a factor that contributed to the dryness?

"Do you change your nail polish regularly?" and "How often do you apply moisturizer to your feet?"

Which interpretation would the nurse make after observing a patient's skin that lifts easily and falls immediately back to its resting position?

This indicates a normal skin finding.

Which assessment information is obtained when the nurse palpates a patent's skin

Turgor, texture, moisture, and thickness

Which site would the nurse assess to determine the status of circulation to the hand?

Ulnar and radial

Which principle would the nurse remember when assessing skin turgor?

When tenting occurs, skin turgor is poor; Body fluid levels regulate skin turgor; Dehydration diminishes skin turgor.

To which physical examination technique is the nurse referring to when stating, "You need to have good visual, hearing, and olfactory abilities to perform this technique"?

inspection

Which pulse is difficult to palpate in a normal patient?

popliteal pulse

While assessing a patient, the nurse finds that the radial pulse is abnormal. Which pulse would the nurse assess next in this situation?

Apical

While assessing the strength of a pulse in a patient, the nurse rates it as 3. Which statement is true regarding the rating?

Full, increased

The nurse observes the presence of a tympanic note when percussing the abdomen of a patient and suspects which cause?

Gas

Which conclusion would the nurse make about a patient whose nails have concave curves?

Has anemia

Which condition causes blush discoloration of the skin and mucous membrane?

Hypoxia

Which technique would the nurse use to assess for jaundice?

Inspect the sclera and mucous membranes for a yellowish-orange tint.

Which statement about palpation is correct?

It involves the use of different parts of the hand to detect various characteristics of body parts, and it is a physical examination technique that involves using the sense of touch to gather information.

During a physical examination of a patient, which area of the body would the nurse assess for cyanosis?

Lips, skin, and nail beds.

In which order would the nurse complete the steps of assessing the skin of a patient for carcinoma?

Look for an uneven shape, looking for edges that are blurred, notched, or ragged; looking for pigmentation that is not uniform; and looking for areas greater than 6mm.

How would the nurse examine the organs in the abdomen to evaluate abdominal pain?

Palpate the abdomen by applying deep pressure with one or both hands.

Which technique is the nurse performing when using the sense of touch with the surface of the hand to collect clinical data about a patient's skin?

Palpation

Which physical examination technique is required when assessing a patient?

Palpation, percussion, and auscultation

How does the nurse measure a brachial pulse?

Placing the fingertips of the first three fingers in the groove between the biceps

Which site would the nurse assess to determine the status of circulation to the lower leg?

Popliteal

Which pulse site would the nurse assess for circulation of blood to the foot?

Posterior tibial and dorsalis pedis

Which condition causes enlargement of the fingertips and flattening of the nail, resulting in a large angle between the nail and nail base?

Pulmonary disease

For which reason would the nurse instruct the student nurse to avoid deep palpation during physical assessment?

Rib fractures

Which characteristic of the skin is measured using the dorsum of the hand?

Temperature