NUR 2058 - Health Assessment Exam 2: Study Guide. Questions with Answers. Rationales Provided. Complete Solutions Guide.
Health Assessment Exam 2:
... [Show More] Study Guide
Chapter 08:
1. When performing a physical assessment, the first technique the nurse will always use is:
a. Palpation.
b. Inspection.
c. Percussion.
d. Auscultation.
B
The skills requisite for the physical examination are inspection, palpation, percussion,
and auscultation. The skills are performed one at a time and in this order (with the
exception of the abdominal assessment, during which auscultation takes place before
palpation and percussion). The assessment of each body system begins with inspection. A
focused inspection takes time and yields a surprising amount of information.
2. 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 patient’s
body systems before proceeding with
palpation.
B
A focused inspection takes time and yields a surprising amount of information. Initially,
the examiner may feel uncomfortable, staring at the person without also doing something.
A focused assessment is significantly more than a “quick glance.”
3. The nurse is assessing a patient’s skin during an office visit. What part of the hand and
technique should be used to best assess the patient’s 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
The dorsa (backs) of the hands and fingers are best for determining temperature because
the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine,
tactile discrimination. The other responses are not useful for palpation.
4. 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
Palpation uses the sense of touch to assess the patient for these factors. Inspection
involves vision; percussion assesses through the use of palpable vibrations and audible
sounds; and auscultation uses the sense of hearing.
5. The nurse is preparing to assess a patient’s 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
Light palpation is initially performed to detect any surface characteristics and to
accustom the person to being touched. Tender areas should be palpated last, not first.
6. 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
Bimanual palpation requires the use of both hands to envelop or capture certain body
parts or organs such as the kidneys, uterus, or adnexa. The other situations are not
appropriate for bimanual palpation.
7. 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
Percussion yields a sound that depicts the location, size, and density of the underlying
organ. Turgor and texture are assessed with palpation.
8. 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
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