Chapter 6: Health Assessment

MULTIPLE CHOICE 1. The nurse is visiting the patient for the first time this shift. She introduces herself and asks the patient several questions related to his condition. While doing so, and without being obvious, she is looking at the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth. Which assessment technique is the nurse using? a. Palpation b. Percussion c. Inspection d. Auscultation ANS: C Inspection is the visual examination of body parts or areas. An experienced nurse learns to make multiple observations, almost simultaneously, while becoming very perceptive of abnormalities. Palpation uses the sense of touch. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities. Auscultation is listening with a stethoscope to sounds produced by the body. DIF: Cognitive Level: Application REF: Text reference: p. 108 OBJ: Describe the techniques used with each assessment skill. TOP: Inspection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The patient is admitted with fever and acute lower abdominal pain. He has taken Tylenol but says he still feels feverish. Before taking the patient’s temperature, the nurse may: a. touch the patient’s skin with the dorsum of her hand. b. touch the patient’s skin with the pads of her fingers. c. palpate the skin using the bimanual method. d. tap the patient’s skin using the fingertips. ANS: A The dorsum (back) of the hand is more sensitive to temperature variations. The pads of the fingertips detect subtle changes in texture, shape, size, consistency, and pulsation of body parts. Bimanual palpation involves one hand placed over the other while pressure is applied. The upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses. Seek the assistance of a qualified instructor before attempting deep palpation. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities. DIF: Cognitive Level: Application REF: Text reference: p. 108 OBJ: Describe the techniques used with each assessment skill. TOP: Palpation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity