Chapter 8

Question 1

What are the skills requisite for the physical examination?

Answer 1

Inspection

Palpation

Percussion

Auscultation

Question 2

What should the student nurse know about inspection?

Answer 2

Inspection always comes first, it is the general survey of a person. During inspection compare the patient’s right side with left side; the two sides are nearly symmetric. During inspection make sure you have good lighting and adequate exposure.

Question 3

Describe what the student nurse should know about palpation.

Answer 3

Palpation confirms points you noted during inspection; applies your sense of touch to assess these factors:

1. texture
2. temperature
3. moisture
4. organ location
5. size 6. swelling
6. vibration/pulsation
7. rigidity/spasticity
8. crepitating
9. lumps/masses
10. tenderness/pain

Question 4

When should you use you fingertip in palpation?

Answer 4

During palpation you fingertips are best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps.

Question 5

When should a grasping action be used in palpation?

Answer 5

A grasping action of the fingers and thumb can be used during palpation to detect the position, shape, and consistency of an organ or mass.

Question 6

Which side of the hand is best for determining temperature?

Answer 6

The dorsa (backs) of hands and fingers are best for determining temperature during palpation because the skin here is thinner than on the palms.

Question 7

Describe how vibrations are palpated for.

Answer 7

The base of the fingers (metacarpophalangeal joints) or ulnar surface of the hand are best for palpating vibration.

Question 8

Why does the nurse tap the person’s skin with short, sharp strokes?

Answer 8

Percussion is tapping the person’s skin with short, sharp stroke to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ.

Question 9

Why is percussion used?

Answer 9

Percussion is used to map out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors; percussion signals the density (air, fluid, or solid) of a structure by a characteristic note.

Question 10

What are the two methods for percussion?

Answer 10

Percussion has two methods direct or immediate and indirect or mediate.

Question 11

Describe the direct method of percussion?

Answer 11

The direct (immediate) method has the striking hand directly contacting the body wall. This produces a sound and is used in percussing the infant’s thorax or the adult’s sinus areas

Question 12

Describe the indirect method of percussion?

Answer 12

The indirect (mediate) method is used more often and involves both hands. The striking hand contacts the stationary hand fixed on the person’s skin. This yields a sound and a subtle vibration

Question 13

What are the five characteristics of percussion note?

Answer 13

Resonant, hyper resonant, tympany, dull, flat.

Question 14

What are the characteristics of a resonant percussion note.

Answer 14

Amplitude: medium-loud amplitude,

Pitch: low

Quality: clear and hollow

Duration: moderate

Location: over normal lung tissues.

Question 15

What are the characteristics of a hyperresonant percussion note.

Answer 15

Amplitude: Louder

Pitch: Lower

Quality: Booming

Duration: Longer

Location: Normal over child’s lung; abnormal in the adult, over lungs with increased amount of air, as in emphysema

Question 16

Describe a tympany percussion note?

Answer 16

Amplitude: Loud

Pitch: High

Quality: Musical and Drumlike (like the kettle drum)

Duration: Sustained longest

Location: Over air filled viscus, e.g the stomach and intestines

Question 17

What are the characteristics of a dull percussion note?

Answer 17

Amplitude: Soft

Pitch: High

Quality: Muffled Thud

Duration: Short

Location: Relatively dense organs, as in liver or spleen

Question 18

What is a flat percussion note?

Answer 18

Amplitude: Very soft

Pitch: High

Quality: A dead stop of sound, absolute dullness

Duration: Very Short

Location: When no air is present, over thigh muscles, bone, or over tumor

Question 19

What should the student nurse know about auscultation?

Answer 19

Auscultation is listening to sounds produced by the body, such as the heart and blood vessels and the lungs and abdomen.

Question 20

Which side of the stethoscope is used to listen to high pitched sounds such as breath sounds, bowel, and normal heart sounds.

Answer 20

The diaphragm.

Question 21

What is the bell used for?

Answer 21

The bell of the stethoscope is used to listen to soft, low pitched sounds such extra heart sounds, or bruits, murmurs.

Question 22

Opthalmoscope

Answer 22

Question 23

Describe the sequence, preparation, and sequence for assessment of an infant.

Answer 23

Position

• parent should be present
• flat on exam table
• 6 months – sitting on parent’s lap
• 9-12 months – parents must be in full view

Preparation

• 1-2 hrs. after feeding
• nude
• soft voice

Sequence

• if sleeping – listen to heart, lungs & abdominal sounds first
• less distracting - first
• eye, ear, nose & throat - last

Question 24

Describe the sequence, preparation, and sequence for assessment of a toddler.

Answer 24

Erikson’s stage of developing autonomy

Position

• Sitting on parent’s lap

Preparation

• Symbols/security objects
• Have parent undress
• Don’t give choices, unless limited options
• Praise for cooperation

Sequence

• Collect data during health assessment
• Note gross & fine motor skills
• Begin w/ “games” (Denver II test or cranial nerve testing)
• Start w/ non-threatening areas
• Head, ear, nose, throat - last

Question 25

What is the position, preparation, and sequnce of assesment for the preschool child.

Answer 25

Displays developing initiatives; Takes on tasks independently; plans & see through; Often cooperative, helpful, and easy to involve. Position * Parents should be present * Hold on lap Preparation * Verbal communication important Sequence * Allow child to play w/ equipment * Use games * Thorax, abd, extremities & genitalia – first * Head, eye, ear, & throat - last

Question 26

What is the position, preparation, and sequnce of assesment for the school aged child.

Answer 26

Position * Sitting or lying Preparation * Demonstrate equipment Sequence * Head-to-toe

Question 27

What is the position, preparation, and sequnce of assesment for the adolescent?

Answer 27

Major task developing self identity; Peer group values and acceptance are important. Position * They should be sitting on the table Preparation * During the examination the adolescent needs feedback that his or her own body is healthy and developing normally. Sequence * As with adult, a head to toe approach is appropriate. Examine genitalia last and do it quickly

Question 28

What is the position, preparation, and sequnce of assesment for the aging adult?

Answer 28

Tasks are developing the meaning of life and one’s own existence and adjusting to changes in physical strength. Position * sitting on the examination table; allow rest periods when needed Preparation * adjust examination pace to meet the possible slowed pace of the aging person; use physical touch (unless there is a cultural contraindication). Sequence * head to toe