Basic Assessment

Question 1

Sitting position listens for:

Answer 1

listening to heart, lungs, BP

Question 2

Supine position

Answer 2

checking skin, pulses, swelling

Question 3

Basic assessment order

Answer 3

Inspect
Palpate
Percussion
Auscultation

Question 4

Least invasive to most invasive

Answer 4

inspection

Question 5

Hear movements of air, blood, or fluid in the body over lungs & abdomen

Answer 5

Auscultation

Question 6

What are you listening for when you are using stethoscope?

Answer 6

intensity, pitch, duration, and quality

Question 7

Optimize quality of findings for auscultation?

Answer 7

Quiet room
Stethoscope directly on skin
If client is cold and shivers—may interfere
Friction of body hair rubbing–could mistaken for abnormal lung sounds (crackles)

Question 8

Percussion is evaluated to: 3

Answer 8

Evaluate size, borders, and consistency of internal organs
Detect tenderness
Determine extent of fluid in a body cavity

Question 9

percussion sounds determine:

Answer 9

location, size, and density of structures

Question 10

tapping over middle finger

Answer 10

indirect percussion

ex: percuss over lung tissue

Question 11

striking finger or hand directly against client’s body

Answer 11

direct percussion

Question 12

five percussion tones

Answer 12

Tympany
Resonance 
Hyperresonance
Dullness 
Flatness

Question 13

loud, high-pitched sound heard over abdomen

Answer 13

Tympany

Question 14

heard over normal lung tissue

Answer 14

Resonance

Question 15

heard in overinflated lungs, as in emphysema

Answer 15

hyperresonance

Question 16

Heard over liver

Answer 16

dullness

Question 17

heard over bone & muscle

Answer 17

Flatness

Question 18

Use of hands to feel texture, size, shape, consistency, location of certain parts, and identify painful or tender areas

Answer 18

Palpation

Question 19

With palpation, what are you measuring for skin? (6)

Answer 19

Temp
 moisture
texture
turgor
tenderness
thickness

Question 20

With palpation, what are you measuring for abdomen? (3)

Answer 20

tenderness, distension or masses

Question 21

What part of hands are more sensitive?

Answer 21

palmar surface & finger tips

Question 22

Ulnar surface of hand to fifth finger is

Answer 22

is most sensitive to vibration

Question 23

Dorsal surface is better for

Answer 23

assessing temperature

Question 24

Light palpation is

Answer 24

1 cm

Question 25

light palpation is used to assess

Answer 25

assess skin, pulsations, and tenderness

Question 26

deep palpation is what depth? and what does it assess?

Answer 26

4 cm & used to determine organ size and contour

Question 27

palpation uses both hands, one anterior, one posterior, to entrap an organ or mass between fingertips to assess size and shape

Answer 27

Bimanual palpation

Question 28

assessment steps for abdomen

Answer 28

Inspect Auscultate Percuss Palpate