Chapter 8: Assessment techniques and safety

Question 1

What is the first step in the nursing process?

Answer 1

Assessment . It is obtained in order to diagnose, plan, implement, and evaluate the plan of care.

Question 2

What are the four basic basic techniques of the physical examination?

Answer 2

(1) inspection, (2) palpation, (3) percussion, and (4) auscultation

Question 3

Guidelines for inspection include:

Answer 3

Having adequate lighting—daylight or artificial
Conducting unhurried and careful inspection
Exposing what you want to inspect
Validating findings with patient
Ensuring appropriate equipment is available

Question 4

Accurate inspection requires

Answer 4

adequate lighting to observe for contour and variations in the body surface.

Question 5

When conducting the assessment of a new patient, inspection begins with which step?

Answer 5

General inspection of the patient

Question 6

What is included as part of the general inspection?

Answer 6

Observing overall appearance of patient

Question 7

Which component is included as part of a systematic inspection?

Answer 7

Inspecting each body region, in a head to toe fashion, is a component of a systematic inspection.

Question 8

Palpation

Answer 8

a technique used in physical examination in which the examiner feels the texture, size, consistency, and location of certain body parts with the hands

Question 9

Guidelines for palpation include:

Answer 9

Keep fingernails short to avoid hurting the patient.

Have warm hands and be gentle in approach to assist the patient in relaxing in order to obtain more accurate data.

Use correct palpation depth and the appropriate part of the hand to correctly identify findings without producing unnecessary discomfort to the patient.

Question 10

When does palpitation not follow after inspection?

Answer 10

When assessing the abdomen, always perform palpation after inspection and auscultation. Palpation may increase the patient’s intestinal activity, causing misleading auscultation findings, such as increased bowel sounds.

Question 11

Different areas of the hands are useful for eliciting specific palpation assessment findings. True or false ?

Answer 11

True

Question 12

Palmar surface of the fingers and finger pads

Answer 12

Position, texture, size, consistency, fluid, crepitus, form of a mass, or structure

Question 13

Ulnar surfaces of hand and fingers

Answer 13

Vibration

Question 14

Dorsal surface of hand

Answer 14

Temperature and moisture

Question 15

Entire hand

Answer 15

Muscle strength

Question 16

Light palpation is best used to obtain which assessment data?

Answer 16

Moisture of skin, temperature, tenderness, pulsation or superficial masses and lesions

Question 17

Bimanual palpation is best used to assess which area of the body?

Answer 17

Female reproductive organs

Question 18

Percussion

Answer 18

Uses sound waves to gather information about the density of tissue. Provide information about tenderness or the amount of fluid within a body cavity.

Question 19

Where is resonance heard?

Answer 19

Is heard over the lungs and dullness is heard over the liver

Question 20

The nurse would expect to hear which tones when percussing the patient’s liver?

Answer 20

Dullness, a soft high-pitched thudding sound, is heard over dense organs, such as the liver.

Question 21

The nurse percusses the patient’s chest and notes a loud, low, hollow tone. The nurse notes this is an expected finding when assessing over which body area?

Answer 21

Lungs
Lungs have a resonant sound that is a loud, low, hollow tone

Question 22

Match the body area with the expected tone heard during percussion.

Answer 22

Healthy lung tissue- resonant
Muscle of thigh- flat
Abdomen over stomach- tympanic
Abdomen over liver- dull

Question 23

The nurse is preparing to use the middle finger of the dominant hand to tap on the middle finger of the nondominant hand, which is placed on the patient’s chest. Which type of percussion is the nurse using?

Answer 23

Indirect percussion uses the middle finger of the dominant hand to tap on the middle finger of the nondominant hand, which is placed on the patient.

Question 24

Which techniques help identify percussion tones?

Answer 24

Striking with the fingertips

Question 25

Auscultation

Answer 25

involves listening for sounds produced by the body or organs within the body, usually the heart, lungs, intestines, and blood vessels

Question 26

While completing auscultation, the nurse should consider a few issues that may impede accuracy of the assessment or have an impact on patient safety.

Answer 26

Close your eyes and reduce surrounding noise to better focus on auscultation sounds. Focus on one sound at a time and carefully distinguish it from other internal body sounds. Warm the stethoscope head before placing it on the patient’s skin to prevent shivering, which can interfere with accurate listening. Be mindful that friction from body hair rubbing against the stethoscope diaphragm may mimic abnormal sounds like crackles. Always clean the stethoscope between patients to prevent cross-contamination and the spread of infection.

Question 27

Which techniques help correctly identify auscultation sounds?

Answer 27

Listening for the presence of sound Noticing the characteristics of sound Angling the stethoscope earpieces in the ear correctly Placing the stethoscope on the patient’s skin

Question 28

The nurse auscultates to obtain which assessment information?

Answer 28

Sounds produced by internal organs The sound of heart valves closing Expected movement of air or fluid through internal organs The temperature and texture of skin

Question 29

Which condition is necessary for accurate inspection?

Answer 29

Adequate time to complete exam Inspection should be careful and unhurried to ensure accurate findings.

Question 30

What components are included in a general inspection of the patient?

Answer 30

Overall color of skin Symmetry of body Obvious injuries

Question 31

Which part of the hand would the nurse use to palpate pulsations?

Answer 31

Finger pads

Question 32

Which tone would the nurse expect to hear when percussing over the stomach?

Answer 32

Tympany

Question 33

Which tone would the nurse expect to hear when percussing over bone or muscles?

Answer 33

Flatness

Question 34

What percussion tone would indicate air-filled (emphysematous) lungs?

Answer 34

Hyperresonance

Question 35

Which techniques are required to conduct accurate percussion?

Answer 35

Downward snap the striking finger Tap sharply and rapidly Use the tip of the finger to strike Have short fingernails

Question 36

Which auscultation techniques are correct for auscultating the heart and lungs?

Answer 36

Isolate each sound and listen to it separately Focus on the characteristics of each sound

Question 37

What guidelines should the nurse follow to ensure that auscultation sounds are accurately heard?

Answer 37

Ensure that the stethoscope endpiece is firmly held against the skin

Question 38

Which tone would the nurse expect to hear when percussing over the lungs?

Answer 38

Resonance

Question 39

During an abdominal assessment, palpation occurs after auscultation for what reason?

Answer 39

Palpation may increase intestinal activity.

Question 40

Which part of the hand is best used to assess for fremitus, or vibrations?

Answer 40

Ball of hand

Question 41

Which part of the hand is used to palpate the patient’s abdomen?

Answer 41

Finger pads

Question 42

To ensure accurate findings, what information would the nurse verify prior to beginning inspection?

Answer 42

Overhead lighting and a lamp are available.

Question 43

The diaphragm of the stethoscope

Answer 43

used to hear high-pitched sounds. High-pitched body sounds include lung sounds, bowel sounds, and normal heart sounds. The diaphragm must be held firmly on the skin during use

Question 44

The bell of the stethoscope

Answer 44

used to hear soft, low-pitched sounds such as extra heart sounds, heart murmurs, and vascular sounds (bruits)

Question 45

Standard precautions

Answer 45

the precautions you will take with every patient encounter, such as handwashing and wearing gloves as appropriate.

Question 46

Supine

Answer 46

Lying flat on the back.

Question 47

Prone

Answer 47

Lying flat on the stomach.

Question 48

Fowler’s Position

Answer 48

The head of the bed is elevated at various angles (high, semi, or low).

Question 48

Dorsal Recumbent

Answer 48

Lying on the back with knees bent and feet flat