Chapter 3: Techniques and Equipment for Physical Assessment

Question 1

The ulnar aspect of the hand

Answer 1

may be used to detect vibration

Question 2

A transilluminator is used to detect

Answer 2

fluid within a body cavity

Question 3

Tones with a booming quality

Answer 3

A booming quality is associated with a hyperresonant tone.

Question 4

The thickness of tissue can impair vibrations

Answer 4

causing quieter percussion tones.

Question 5

1 cm is appropriate for

Answer 5

superficial or light palpation

Question 6

Deep palpation is done

Answer 6

with one or two hands to a depth of 1.6 inches or 4 cm.

Question 7

A Wood’s lamp is used to detect

Answer 7

fungal infections of the skin. Lesions of the skin appear as a fluorescent yellow-green or blue-green color.

Question 8

A slit lamp might be used to detect

Answer 8

a foreign body embedded in the eye

Question 9

Resonance

Answer 9

is heard over healthy lung tissue

Question 10

hyperresonance

Answer 10

is heard in overinflated lungs (as in emphysema)

Question 11

Dullness is heard

Answer 11

over the liver

Question 12

tympany

Answer 12

is normally heard over the abdomen

Question 13

flatness is heard over

Answer 13

over bones and muscle. Detecting sound changes is easier when moving from resonance to dullness (e.g., from the lung to the liver).

Question 14

inspection refers to

Answer 14

visual examination of the body, including
body movement and posture. Data obtained by smell are
also a part of inspection

Question 15

inspecting the lungs and respiratory system

Answer 15

the nurse
observes the shape of the chest, giving attention to breathing
(noting the rate, depth, and effort of respirations); and notices
the overall color of the skin, lips, and nail beds

Question 16

a technique

referred to as tangential lighting

Answer 16

penlight to create shadows by directing

light at right angles to the area being inspected—

Question 17

bimanual technique of palpation

Answer 17

uses both
hands, one anterior and one posterior, to entrap a mass or an
organ (such as the uterus, kidney or large breasts) between
the fingertips to assess size and shape

Question 18

Light palpation should

always precede deep palpation

Answer 18

because palpation may cause tenderness or disrupt fluid, which could interfere with collecting
data by light palpation

Question 19

Direct percussion involves

Answer 19

striking a finger or hand directly

against the patient’s body.

Question 20

Indirect percussion

Answer 20

requires both hands and is done by different
methods, depending on which body system is being
assessed.

Question 21

tympany

Answer 21

abdomen

Question 22

resonance

Answer 22

healthy lung tissue

Question 23

hyperresonance

Answer 23

inflated lungs (emphsema)

Question 24

dullness

Answer 24

liver

Question 25

flatness

Answer 25

bones and muscle

Question 26

Listen for the sound | and its characteristics:

Answer 26

intensity, pitch, duration, and quality

Question 27

lungs

Answer 27

``` resonant loud low long hollow ```

Question 28

bone and muscle

Answer 28

``` flat soft high short extremely dull ```

Question 29

viscera and liver borders

Answer 29

``` dull medium medium high medium thudlike ```

Question 30

stomach and gas bubbles in intestines

Answer 30

typmanic loud high medium drumlike

Question 31

air trapped in lung (emphysema)

Answer 31

``` hyperresonant very loud very low longer booming ```

Question 32

intensity

Answer 32

is the loudness of the sound, described as soft, | medium, or loud.

Question 33

pitch

Answer 33

is the frequency or number of sound waves generated per second. High-pitched sounds have high frequencies. Expected high-pitched sounds are breath sounds, whereas cardiac sounds are low pitched

Question 34

Duration of sound vibrations

Answer 34

is short, medium, or long. Layers of soft tissue dampen the duration of sound from deep organs.

Question 35

quality

Answer 35

refers to the description of the sounds (e.g., hollow, | dull, crackle).

Question 36

several types of stethoscopes

Answer 36

acoustic, magnetic, electronic, and stereophonic), the acoustic stethoscope is used routinely for health assessment

Question 37

diaphragm of stethoscope

Answer 37

high-pitched sounds such as breath, bowel, and normal heart sounds. Its structure screens out lowpitched sounds.

Question 38

bell of the stehoscope

Answer 38

It is used to hear soft, low-pitched sounds such as extra heart or vascular sounds (bruit)

Question 39

automated BP cuff operates

Answer 39

by sensing circulating blood flow vibrations through a blood pressure cuff sensor and converting these vibrations into electric impulses

Question 40

select a blood pressure | cuff that is the correct size for the patient

Answer 40

If the cuff is too wide, it underestimates the blood pressure; if it is too narrow, it overestimates the blood pressure. Ideally the cuff width should be 40% of the circumference of the limb to be used. The bladder within the cuff should encircle at least 80% of the upper arm

Question 41

The pulse oximeter

Answer 41

used to measure the oxygen saturation in arterial blood, consists of a light-emitting diode (LED) probe connected by a cable to a monitor

Question 42

paO2 LED light waves reflect off....

Answer 42

oxygenated and deoxygenated hemoglobin molecules circulating in the blood. This reflection is used to estimate the percentage of oxygen saturation in arterial blood and a pulse rate.

Question 43

paO2 placement

Answer 43

The sensor probe is taped or clipped to a highly vascular area—typically a digit (finger or toe), an earlobe, or the bridge of the nose

Question 44

Snellen chart

Answer 44

a wall chart hung at a distance of 20 feet | from the patient

Question 45

E chart

Answer 45

used for young children and non english speaking individuals

Question 46

Two charts, the Rosenbaum and the Jaeger

Answer 46

are commonly | used to evaluate near vision

Question 47

transilluminator

Answer 47

is used to differentiate the characteristics | of tissue, fluid, and air within a specific body cavity.

Question 48

monofilament

Answer 48

is a small, flexible, wirelike device attached to a handle (Fig. 3-27, A) used to test for sensation on the lower extremities.

Question 49

The Wood’s lamp produces a black-light effect

Answer 49

is used to | detect fungal infections of the skin or corneal abrasions