question

Skills required for physical examination

answer

Inspection, palpation, percussion, auscultation

question

Inspection

answer

Concentrated watching; first of person as a whole and then of each body system.

question

Palpation

answer

Confirms points noted in inspection, applies sense of touch to exam. Assesses texture, temperature, moisture, organ size/location, and any swelling.

question

Percussion

answer

Tapping person's skin with short, sharp, strokes, to assess underlying structures.

question

Mapping out location and size of organ

answer

Percussion

question

Signaling density (air, fluid, or solid) of a structure by a characteristic note

answer

Percussion

question

Detecting an abnormal mass

answer

Percussion

question

Auscultation

answer

listening to sounds produced by the body (heart, lungs, abdomen)

question

Diaphragm of stethoscope

answer

high pitched sounds (breath, bowel, normal heart sounds)

question

Bell of stethoscope

answer

soft, low-pitched sounds - extra heart sounds or murmurs

question

Amplitude

answer

loud or soft sound

question

pitch

answer

frequency, number of vibrations per second

question

quality

answer

(timbre) distinctive overtones of sound

question

duration

answer

length of time note lingers

question

Four areas to consider during general survey:

answer

physical appearance, body structure, mobility, and behavior

question

Reduce the risk of acquiring infection

answer

the CDC recommendations for nurses to wear gloves (2009)

question

Prevent the transmission of flora from healthcare provider to patient

answer

the CDC recommendations for nurses to wear gloves (2009)

question

Reduce transient contamination of the hands of the healthcare provider from patient to patient

answer

the CDC recommendations for nurses to wear gloves (2009)

question

The nurse wants to auscultate the lungs of a patient. What should the nurse do if the patient has excessive chest hair?

answer

Moisten the patient's chest hair.

question

Which position does the nurse instruct the patient with overwhelming fatigue to assume during assessment?

answer

Supine position

question

Which assessment technique should the nurse use to determine the body temperature of a patient?

answer

Touching the patient's skin with the dorsal side of the hands and fingers

question

Which instrument is used to examine both the ear and the nose?

answer

Otoscope

question

While performing chest percussion on a patient, the nurse obtains a loud sound. Under which percussion note characteristic does the nurse document this finding?

answer

Amplitude

question

The nurse has come to the patient's room to perform the physical assessment of a 4-month-old infant. The nurse finds that the child is sleeping. What would the nurse do in this situation?

answer

The nurse would assess the lung, heart, and bowel sounds.

question

Medium-loud, low, clear, hollow, and moderate percussion note

answer

resonant

question

Lung tissue percussion note

answer

resonant

question

louder lower booming longer percussion note

answer

hyperresonant

question

percussion note normal to hear in child's lung but abnormal to hear in an adults lung, with increased amounts of air as in emphysema

answer

hyperresonant

question

Loud, High, Musical and drumlike, sustained longest percussion note

answer

tympany

question

Percussion note over air-filled viscous (stomach, intestine)

answer

tympany

question

Soft, high, muffled thud, short percussion note

answer

dull

question

percussion note heard over dense organs (liver, spleen)

answer

dull

question

Very soft, high, dead stop of sound, absolute dullness, very short percussion note

answer

flat

question

percussion note heard where no air is present, over thigh muscles, bone or tumor

answer

flat

question

Which patients would the nurse assess using the head-to-toe approach?

answer

adolescent, adult, an aging adult, and a school-age child

question

The nurse is assessing a preschool child in a hospital setting. Which interventions will the nurse implement for assessing the child effectively

answer

The nurse should allow the child to play with toys during the assessment to reduce the child's fear and make him or her more cooperative. Because the preschool child feels uncomfortable undressed, the nurse should allow the child to keep the underpants on until the genital examination. Because the preschool child can talk and understand, the nurse can communicate with the child and can explain about the examination during the assessment.

question

While assessing a preschool child which areas should be examined first?

answer

The nurse should assess the thorax, abdomen, extremities, and genitalia first, because the child is cooperative initially, and then nurse can then assess the head, eye, ear, nose, and throat last because those are more threatening areas

Chapter 8 Assessment Techniques Jarvis – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards