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Health Assessment Exam 2: Latest Update 2023 Guaranteed Success
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Chapter 08: When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. B 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 perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert
are more sensitive to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c. Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity.
d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area. B The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The other responses are not useful for palpation. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is
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 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 would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant
b. Texture c. Density d. Consistency C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a. Percussing once over each area b. Quickly lifting the striking finger after each stroke c. Striking with the fingertip, not the
finger pad d. Using the wrist to make the strikes, not the arm A For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm. 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
percuss in this area again. d. Consider this finding as abnormal, and refer the patient for additional treatment. A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct. 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? a. Ask the patient to take deep breaths to relax the
abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen. C The thickness of the person’s body wall
of an increased amount of air in the lungs. d. Consider this finding as normal for a child this age, and proceed with the examination. D Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a child’s lung. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when
further assessing the patient?
which may yield clues of the patient’s physical status. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a. Slope of the earpieces should point posteriorly (toward the occiput). b. Although the stethoscope does not magnify sound, it does block out extraneous room noise. c. Fit and quality of the stethoscope are
not as important as its ability to magnify sound. d. Ideal tubing length should be 22 inches to dampen the distortion of sound. B The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner’s nose. Long tubing will distort sound. The fit and quality of the stethoscope are both important. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the
