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_ is the first technique used in physical assessment. However, it is used _.

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inspection, throughout

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inspection begins the moment the nurse _ the client

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meets

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inspection moves from _ to _

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general, specific

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inspection requires _

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bright lighting

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_ includes the sense of smell

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inspection

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inspection requires _ skills

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critical thinking

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inspection may determine _

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symmetry

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inspection can be done _

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independently

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_ nurses usually feel uncomfortable with inspection

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novice

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lymph nodes

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light palpation; hand surface (finger pads)

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liver

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deep palpation; hand surface (palmar surface fingers)

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skin texture

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light palpation; hand surface (finger pads)

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skin temperature

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light palpation; hand surface (dorsal surface)

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pulses

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light palpation; hand surface (finger pads)

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fremitus (assessment of the lungs by either the vibration intensity felt on the chest wall)

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moderate palpation; hand surface (base of fingers or ulnar surface )

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high pitched soft tone of short duration

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dullness

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low pitched, loud, hollow tone of long duration

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resonance

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sound heard when percussing over solid body organs

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dullness

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sound heard when percussing over air filled intestines

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tympany

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sound heard when percussing hyperinflated lungs

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hyperresonance

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high pitced, loud, drumlike tone of medium duration

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tympany

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abnormally loud tone of long duration

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hyperresonance

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sound heard when percussing over bone

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flatness

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sound heard when percussing over air filled lungs

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resonance

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high, pitched soft tone of short duration

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dullness

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which of the following sequences used during physical assessment reflects the proper order for the nurse to assess a client?

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inspection, palpation, percussion, ausculation

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a young adult is involved in a motorcycle crash and sustains injuries to the right leg. as the nurse inspects the clients injured leg, it is best to proceed from:

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the entire leg then proximal to distal Rationale: The entire leg should be assessed, then proceed proximal to distal. This process allows the nurse to obtain a general overview and then focus on the most lifethreatening injuries. (Example: The femoral artery is in the groin and assessed first, then more peripheral pulses should be palpated.)

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the nurse uses _ percussion when assessing the thorax of an infant

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direct Rationale: Direct percussion is used to assess the thorax of an infant, not indirect. Blunt percussion is used to assess the gallbladder, liver, and kidneys.

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when using the opthalmoscope to inspect the interior structures of the eye, the nurse identifies an abnormal finding. the best aperture to use to further assess a lesion would be a:

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grid Rationale: The grid is best to utilize so the nurse can accurately describe and document the size, location, and pattern of any lesions. The small aperture is used for undilated pupils. The slit allows for examination of the anterior eye and aids in assessing the elevation of depression of lesions. The red-free filter shines a green beam used to examine the optic disc for pallor or hemorrhaging, which appears black with this filter.

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two agencies that help to establish protocols to protect both nurses and clients from the spread of disease are ?

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the CDC and OSHA

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a nursing student is performing a physical assessment in the clinical setting. the nursing instructor provides further teaching when the student?

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performs hand hygiene only at the beginning of the assessment

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the nurse is preparing to assess the fetal heart of a client who is 5 months pregnant using a droppler ultrasonic stethoscope. the nurse understands in order to accurately obtain the fetal heart rate it is important to

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use a transducer gel Rationale: A transducer gel will aid in transmission of sound waves to obtain the best reading. Heavy pressure is not needed in most cases. The transducer should be warmed, not cooled, before applying to a client's skin. The client does need to hold her breath unless the nurse needs to ensure the fetal heart is being heard and not the mother's

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the nurse is palpating the peripheral pulses of an older adult client. important factors for the nurse to consider when performing this type of assessment are (SATA) 1. making certain fingernails are short and smooth 2. not wearing jewlery 3. assessing the client for a latex allergy 4. performing hand hygiene 5. putting on sterile gloves for the assessment

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1,2,4 Rationale: Fingernails should be short so as not to injure the client. Wearing jewelry could potentially interfere with assessment, especially necklaces and large rings. Jewelry could attract bacteria as well. Sterile gloves are not necessary. Clean hands can be used; and clean gloves are recommended if the nurse is palpating over any breaks in the client's skin integrity. Hand hygiene is important to

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the nurse is assessing the abdomen of a client who may be identified with hepatitis B. in order to assess for hepatomegaly the nurse will palpate?

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2-4 cm deep over the RUQ Rationale: The liver is palpated deeply; 2-4 cm over the right upper quadrant. The liver is usually not palpable by light palpation.

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the nurse is caring for an adult client weighing >400 lb. which blood pressure cuff is most appropriate to measure the blood pressure on the clients arm?

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cuff with bladder width of 40% to 50% of arm circumference Rationale: An obese client likely requires a large cuff that is accurately fitted by measuring a cuff bladder width of 40%-50% of arm circumference.

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The nurse is preparing to assess a middle-aged client. What should the nurse do first? Hint: Basic Techniques of Physical Assessment; Inspection

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Inspection Inspection always precedes the other assessment skills and is never rushed. The order of assessment techniques is: inspection, palpation, percussion, and auscultation, except when assessing the abdomen, where the techniques are inspection, auscultation, percussion, and palpation.

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A client comes into the clinic with the complaint of swollen ankles. The nurse will utilize which assessment technique to find out more information about this client? Hint: Basic Techniques of Physical Assessment; Palpation

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Palpation Palpation is the use of touch to assess specific body characteristics, which include size, shape, location, mobility, position, vibration, temperature, texture, moisture, tenderness, and edema. Palpating the ankle will give the nurse information about tenderness, temperature, mobility, and edema characteristics. Visual inspection is also included in the assessment of the ankles, but palpation will yield the most information. Percussion and auscultation are not techniques used to assess the ankles.

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A client comes into the clinic with acute right lower quadrant abdominal pain. During the abdominal assessment of this client, the nurse should: Hint: Basic Techniques of Physical Assessment; Palpation

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palpate the area last Known painful areas of the body are usually the last areas to be palpated. Palpating the painful area first would not only increase the client's discomfort, but could also alter the assessment of the rest of the abdomen. Deep palpation should be used with caution, especially if one suspects that there is inflammation, peritonitis, or ectopic pregnancy. The area should be assessed using light to moderate palpation.

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The nurse is preparing to assess a client with flank pain, discomfort with voiding, and pink-tinged urine. Which assessment technique should the nurse use? Hint: Basic Techniques of Physical Assessment; Percussion

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Blunt percussion Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys. With blunt percussion, the palm of the nondominant hand is flat against the body, and a closed fist is used to strike the hand on the body. Direct percussion is tapping the body directly to examine the sinuses or the thorax of an infant. Reflexive percussion is not an assessment technique. Indirect percussion is the most common method used to produce sounds within the body. To perform indirect percussion, the middle finger of the nondominant hand is placed firmly over the area being examined. The middle finger of the dominant hand quickly strikes the middle finger of the nondominant hand, producing vibrations and a sound.

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During the percussion of a client's abdomen, the nurse hears a loud, high-pitched, drumlike tone. The nurse should document this finding as: Hint: Basic Techniques of Physical Assessment; Percussion

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tympany Tympany is a loud, high-pitched, drumlike tone of medium duration commonly heard over the stomach or intestines. Resonance is a loud, low-pitched sound heard over the lungs. Hyperresonance is a loud, long sound heard when air is trapped in the lungs. Flatness is a soft, short sound heard over solid tissue such as bone.

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While auscultating the abdomen of a client, the nurse recognizes the bowel sounds are long. The nurse understands this refers to: Hint: Basic Techniques of Physical Assessment; Auscultation

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duration Duration refers to the length of time of the produced sound. This time frame ranges from very short to very long with variation in between. Intensity refers to the softness or loudness of the sound. Pitch refers to the number of vibrations of sound per second. Quality refers to the overtones produced by the vibration such as clear, hollow, muffled, or dull.

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The nurse places the bell of the stethoscope on a client in order to assess: Hint: Equipment; Stethoscope

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heart murmur The bell detects low-pitched sounds such as heart murmurs or bruits in arteries. Lung sounds, normal heart sounds, and abdominal sounds are all considered high-pitched sounds and are assessed using the diaphragm of the stethoscope.

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To assess a client's blood pressure, the nurse will need: Select all that apply. Hint: Table 9.1 Equipment Used During the Physical Assessment a. flashlight b. sphygmomanometer c. gloves d. stethoscope e. watch with a second hand

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stethoscope sphygmomanometer To measure blood pressure, the stethoscope and sphygmomanometer are used. A flashlight, gloves, and a watch with a second hand are not used in the measurement of blood pressure.

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A client complaining of ear pain is assessed by the nurse. What equipment will the nurse use in the assessment of this client? Hint: Special Equipment

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Otoscope An otoscope is used in the assessment of the ear canal and tympanic membrane. Skin-fold calipers are used to determine body fat. A goniometer measures the degree of joint flexion and extension. A penlight is used to examine the pupils, mouth, and pharynx.

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A client with lower-extremity edema comes into the clinic. During the assessment, the nurse is unable to palpate the client's pedal pulses. The nurse should: Hint: Doppler Ultrasonic Stethoscope

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use a Doppler to assess the pulses A Doppler uses ultrasonic waves that can detect the presence of pulses that are not palpable. Doing nothing is not appropriate in this situation since the nurse needs to assess circulation to the affected areas. Elevating the client's legs may help with edema over time, but the client's circulation to the lower extremities should be assessed now. Blood pressure assessment should be done with every client encounter; however, this will not assess the client's circulation in the lower extremities.

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While assessing the lower extremities of a client, the nurse notices several small scabs along the inner aspects of both lower extremities. What is the most appropriate response by the nurse? Hint: Professional Responsibilities; Cues

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"Can you tell me what caused these scabs on your legs?" The nurse is identifying a physical cue that is present during the physical examination. The nurse is attempting to validate the finding, without assuming the cause of the cue. In this case, the nurse is gathering more information about the cause of the scabs. The other options represent assumptions on the nurse's part as far as the cause of the lesions.

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The nurse is preparing to conduct a physical assessment on a young adult with a gaping wound on the right forearm. Before beginning this assessment, the nurse should first: Hint: Providing a Safe and Comfortable Environment

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wash hands The first thing that the nurse should do before beginning the physical examination of any client is to wash the hands. After washing hands, the nurse should put on gloves since the client has a gaping wound. A sterile gown and goggles are not necessary for the examination of this client.

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During the assessment of an obese client, it is necessary for the nurse to place the client in the supine position. The nurse understands while the client is supine, it is most important to monitor this client for: Hint: Assessment of the Obese Patient

answer

respiratory distress In the supine position, the weight of the chest wall and fat in the chest can fatigue the respiratory muscles quickly. The client's respiratory status should be observed continuously while the client is supine, and the head of the bed should be elevated as quickly as possible. The supine position should not cause abdominal pain, fatigue, or difficulty swallowing.

(physical assessment): ch 9: techniques and equipment – Flashcards

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