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Health Assessment Exam 2: Study Guide Chapter 08: 1. When performing a physical assessment, the first technique the nurse will always use is: The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The$10.99
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Health Assessment Exam 2: Study Guide Chapter 08: 1. When performing a physical assessment, the first technique the nurse will always use is: The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The
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Health Assessment Exam 2: Study Guide
Chapter 08:
1. When performing a physical assessment, the first technique the nurse will always use is:
The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and ...
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
each stroke
c. Striking with the fingertip, not the finger
pad
d. Using the wrist to make the strikes, not the
arm
A
For percussion, the nurse should percuss two times over each location. The striking finger
should be quickly lifted because a resting finger damps off vibrations. The tip of the
striking finger should make contact, not the pad of the finger. The wrist must be relaxed
and is used to make the strikes, not the arm.
9. 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
Percussion over relatively dense organs, such as the liver or spleen, will produce a dull
sound. The other responses are not correct.
10. 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 thickness of the person’s body wall will be a factor. The nurse needs a stronger
percussion stroke for persons with obese or very muscular body walls. The force of the
blow determines the loudness of the note. The other actions are not correct.
11. 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
Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long
in duration are normal over a child’s lung.
12. 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?
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