Ch 8 Physical assessment

When performing a physical assessment, the first technique the nurse will always use is:

Inspection

The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:

Takes time and reveals a surprising amount of information

The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature?

Dorsal surface of the hand; the skin is thinner on this surface 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?

Palpation

The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed?

The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

The nurse would use bimanual palpation technique in which situation?

Palpating the kidneys and uterus

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the ____ of the underlying tissue.

Density

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?

Percussing once over each area

When percussing over the liver of a patient, the nurse notices a dull sounds. The nurse should?

Consider this a normal finding

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?

Increase the amount of strength used when attempting to percuss over the abdomen

The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4 year old child. The nurse should?

Consider this finding as normal for a child this age, and process with the examination

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 nest for the nurse to take when further assessing the patient?

Bilaterally percuss the thorax, noting any differences in percussion tones

The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?

Although a the stethoscope does not magnify sound, it does block out extraneous room noise

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphrgam:

Is used to listen for high-pitched sounds

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:

Check the temperature of the room, and offer blankets to the patient if he or she feels cold

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

Palpation

The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope?

Directs light into the ear canal and onto the tympanic membrane

An examiner is using an ophthalmoscope to examine a patients eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed?

Rotating the lens selector dial to bring the object into focus

The nurse is unable to palpate the right radial pulse on a patient. The best action would be to?

Use a Doppler device to check for pulsations over the area

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:

Organizes the assessment to ensure that the patient does not change positions too often

A man is at the clinic for a physical examination. He states that he is very anxious about the physical examination. What steps can the nurse take to make him more comfortable?

Appear unhurried and confident when examining him

When performing a physical examination, safety must be considered to protect examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination?

Hands are washed before and after every physical patient encounter

The nurse is examining a patients lower leg and noticed a draining ulceration. Which of these actions is most appropriate in this situation?

Washing hands, putting on gloves and continuing with the examination of the ulceration

During the examination, offering some brief teaching about the patients body or the examiners findings is often appropriate. Which one of these statements by the nurse is most appropriate?

Your pulse is 80 bpm, which is within the normal range.

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?

Examiner to build rapport and to increase the patients confidence in him or her

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?

At the end of the examination

When preparing to perform a physical examination on an infancy, the nurse should?

Have the parent remove all clothing except the diaper on a boy

A 6 month old infant has been brought to the well child clinic or a check up. She is currently sleeping. What should the nurse do first when beginning the examination?

Auscultaste the lungs and heart while the infant is still sleeping

A 2 year old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to?

Allow the child to keep a security object such as a toy or blanket during the examination

The nurse is examining a 2 year old child and asks, may I listen to your heart now? Which critique of the nurses technique is most accurate?

Children at this age like to say, No. The examiner should not offer a choice when no choice is available

With which of these patients would it be most appropriate for the nurse to use games during the assessment such as having the patient blow out the light on the penlight?

Preschool child

The nurse is preparing to examine a 4 year old child. Which action is appropriate for this age group?

Give the child feedback and reassurance during the examination

When examining a 16 year old male teenager, the nurse should

Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development