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