Chapter 3, HA
Supine position
Back-lying position used for examination of the abdomen (with one small pillow under the head and another under knees); this position also allows easy access for palpation of peripheral pulses
wash both hands with soap and water
Before beginning a physical assessment of a client, the nurse should first
Prone position
Client lies on abdomen with head turned to side; may be used to assess back and mobility of hip joint
Dorsal surface of hand
Part of examiner's hand used to feel for temperature
Fingerpads
Part of examiner's hand used to feel for the fine discriminations: pulses, texture, size, consistency, shape, and crepitus
Ulnar surface or palm of hand
Part of examiner's hand used to feel for vibration, thrills, or fremitus
indirect percussion
The most commonly used method of percussion is
inspection
During a comprehensive assessment, the primary technique used by the nurse throughout the examination is
Diaphragm of stethoscope
Larger end of stethoscope used to detect breath sound, normal heart sounds, and bowel sounds
Standing position
Position used to examine male genitalia and to assess gait, posture, and balance
Lithotomy position
Back-lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum
blunt percussion
When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using
Bell of stethoscope
small end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)
blunt percussion
An adult client visits a clinic and tells the nurse that she suspects she has a urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing
1 1/2-inch diagragm
During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a
hyperresonance
During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit
deep palpation
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
Sitting position
Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities
Sims' position
Side-lying position used during the rectal examination
explain each procedure being performed and the reason for the procedure
To alleviate a client's anxiety during a comprehensive assessment, the nurse should
dorsal surface of the hand
While examining a client, the nurse plans to palpate temperature of the skin by using the
bone
While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's
percussion
While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using
use minimal position changes
While performing a physical examination on an older adult, the nurse should plan to