When performing a physical assessment, the first technique the nurse will always use
... [Show More] is:
a.
Palpation.
b.
Inspection.
c.
Percussion.
d.
Auscultation.
B
The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:
a.
Usually yields little information.
b.
Takes time and reveals a surprising amount of information.
c.
May be somewhat uncomfortable for the expert practitioner.
d.
Requires a quick glance at the patients body systems before proceeding with palpation.
B
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?
a.
Fingertips; they are more sensitive to small changes in temperature.
b.
Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
c.
Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity.
d.
Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.
B
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?
a.
Palpation
b.
Inspection
c.
Percussion
d.
Auscultation
A
The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed?
a.
Palpation of reportedly tender areas are avoided because palpation in these areas may cause pain.
b.
Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience.
c.
The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths.
d.
The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.
D
The nurse would use bimanual palpation technique in which situation?
a.
Palpating the thorax of an infant
b.
Palpating the kidneys and uterus
c.
Assessing pulsations and vibrations
d.
Assessing the presence of tenderness and pain
B
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue.
a.
Turgor
b.
Texture
c.
Density
d.
Consistency
C
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?
a.
Percussing once over each area
b.
Quickly lifting the striking finger after each stroke
c.
Striking with the fingertip, not the finger pad
d.
Using the wrist to make the strikes, not the arm
A
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
a.
Consider this a normal finding.
b.
Palpate this area for an underlying mass.
c.
Reposition the hands, and attempt to percuss in this area again.
d.
Consider this finding as abnormal, and refer the patient for additional treatment.
A
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?
a.
Ask the patient to take deep breaths to relax the abdominal musculature.
b.
Consider this finding as normal, and proceed with the abdominal assessment.
c.
Increase the amount of strength used when attempting to percuss over the abdomen.
d.
Decrease the amount of strength used when attempting to percuss over the abdomen.
C
The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should:
a.
Palpate over the area for increased pain and tenderness.
b.
Ask the child to take shallow breaths, and percuss over the area again.
c.
Immediately refer the child because of an increased amount of air in the lungs.
d.
Consider this finding as normal for a child this age, and proceed with the examination.
D
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 best for the nurse to take when further assessing the patient?
a.
Count the patients respirations.
b.
Bilaterally percuss the thorax, noting any differences in percussion tones.
c.
Call for a chest x-ray study, and wait for the results before beginning an assessment.
d.
Inspect the thorax for any new masses and bleeding associated with respirations.
B [Show Less]