Chapter # 8

When performing a physical assessment, the first technique the nurse will always use is: a. Palpation b. Inspection c. Percussion d. Auscultation

*B. inspection* The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.

The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? (Select all that apply) a) Warm the hands first before touching the patient b) For deep palpation, use one long continuous palpation when assessing the liver c) Start with light palpation to detect surface characteristics d) Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps e) Identify any tender areas, and palpate them last f) Use the palms of the hands to assess temperature of the skin

*a) Warm the hands first before touching the patient* *c) Start with light palpation to detect surface characteristics* *d) Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps* *e) Identify any tender areas, and palpate them last* The hands should always be warmed before beginning palpation. Intermittent pressure rather than one long continuous palpation is used; any tender areas are identified and palpated last. Fingertips are used to examine skin texture, swelling, pulsation, and the presence of lumps. The dorsa (backs) of the hands are used to assess skin temperature because the skin on the dorsa is thinner than on the palms.

Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a. Palpation b. Inspection c. Percussion d. Auscultation

*a. palpation* Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing.

When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a.Consider this a normal finding. b.Palpate this area for an underlying mass. c.Reposition the hands, and attempt to percuss in this area again. d.Consider this finding as abnormal, and refer the patient for additional treatment.

*a.Consider this a normal finding.* Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.

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 drumlike quality of the sounds across the quadrants. This type of sound indicates: a. Constipation b. Air-filled areas c. Presence of a tumor d. Presence of dense organs

*b. Air-filled areas* A musical or drumlike sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines.

The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to: a. Wear protective eye wear at all times b. Wear gloves during any and all contact with patients c. Wash hands before and after contact with each patient d. Clean the stethoscope with an alcohol swab between patients

*c. Wash hands before and after contact with each patient* The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue. a.Turgor b.Texture c.Density d.Consistency

*c. density* Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation.

When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much b. Attempt to perform the entire physical examination during one visit c. Speak loudly and slowly because most aging adults have hearing deficits d. Arrange the sequence of the examination to allow as few position changes as possible

*d. Arrange the sequence of the examination to allow as few position changes as possible* When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially important with the older person because other senses may be diminished.

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? a.Palpation of reportedly "tender" areas are avoided because palpation in these areas may cause pain. b.Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c.The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths. d.The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

*d.The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.* Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a.Palpation b.Inspection c.Percussion d.Auscultation

A Palpation applies the sense of touch to assess 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 the presence of tenderness or pain

The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a. Examiner feel more comfortable and to gain control of the situation b. Examiner to build rapport and to increase the patient's confidence in him or her c. Patient understand his or her disease process and treatment modalities d. Patient identify questions about his or her disease and the potential areas of patient education.

B Sharing information builds rapport and increases the patient's confidence in the examiner. It also gives the patient a little more control in a situation during which feeling completely helpless is often present.

During the examination, offering some brief teaching about the patient's body or the examiner's findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. "Your atrial dysrhythmias are under control." b. "You have pitting edema and mild varicosities." c. "Your pulse is 80 beats per minute, which is within the normal range." d. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs."

C The sharing of some information builds rapport, as long as the patient is able to understand the terminology.

Order for Abdomen?

Inspect, Auscultate, Percuss, Palpate