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NUR 3121 Health Assessment Unit 2 Exam With Complete Solution
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NUR 3121 Health Assessment Unit 2 ExamWith Complete Solution
When performing a physical assessment, the technique the nurse will always
use first is: - ANSWER ANS: inspection.
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, where
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.
The nurse is preparing to perform a physical assessment. Which statement is
true about the inspection phase of the physical assessment? - ANSWER ANS:
Inspection takes time and reveals a surprising amount of information.
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 much more
than a "quick glance."
The nurse is assessing a patient's skin during an office visit. What is the best
technique to use to best assess the patient's skin temperature? Use the: -
ANSWER ANS: dorsal surface of the hand because the skin is thinner than on
the palms.
The dorsa (backs) of hands and fingers are best for determining temperature
because the skin there is thinner than on the palms. Fingertips are best for
,fine, tactile discrimination; the other responses are not useful for palpation.
Which of these techniques uses the sense of touch to assess texture,
temperature, moisture, and swelling when the nurse is assessing a patient? -
ANSWER ANS: Palpation
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.
The nurse is preparing to assess a patient's abdomen by palpation. How
should the nurse proceed? - ANSWER ANS: Start with light palpation to
detect surface characteristics and to accustom the patient to being touched.
Light palpation is performed initially to detect any surface characteristics and
to accustom the person to being touched. Tender areas should be palpated
last, not first.
The nurse would use bimanual palpation technique in which situation? -
ANSWER ANS: Palpating the kidneys and uterus
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.
The nurse is preparing to percuss the abdomen of a patient. The purpose of
the percussion is to assess the underlying tissue: - ANSWER ANS: density.
Percussion yields a sound that depicts the location, size, and density of the
underlying organ. Turgor and texture are assessed with palpation.
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? The nurse: - ANSWER ANS: percusses once over each area.
For percussion, the nurse should percuss two times over each location. The
striking finger should be lifted off quickly 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 it is used to make the strikes, not
the arm.
When percussing over the liver of a patient, the nurse notices a dull sound.
The nurse should: - ANSWER ANS: consider this a normal finding.
Percussion over relatively dense organs, such as the liver or spleen, will
produce a dull sound. The other responses are not correct.
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? - ANSWER
ANS: Increase the amount of strength used when attempting to percuss over
the abdomen.
The thickness of the person's body wall will be a factor. The nurse will need 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.
The nurse hears bilateral louder, longer, and lower tones when percussing
over the lungs of a 4-year-old child. What should the nurse do next? -
ANSWER ANS: Consider this a normal finding for a child this age and proceed
with the examination.
Percussion notes that are louder in amplitude, lower in pitch, of a booming
quality, and longer in duration are normal over a child's lung.
, A patient has suddenly developed shortness of breath and appears to be in
significant respiratory distress. After putting a call in to the physician and
placing the patient on oxygen, which of these is the best action for the nurse
to take when assessing the patient further? - ANSWER ANS: Percuss the
thorax bilaterally, noting any differences in percussion tones.
Percussion is always available, portable, and gives instant feedback regarding
changes in underlying tissue density, which may yield clues of the patient's
physical status.
The nurse is teaching a class on basic assessment skills. Which of these
statements is true regarding the stethoscope and its use? - ANSWER ANS:
The stethoscope does not magnify sound but does block out extraneous
room noise.
The stethoscope does not magnify sound but does block out extraneous
room sounds. The slope of the earpieces should point forward toward the
examiner's nose. Longer tubing will distort sound. The fit and quality of the
stethoscope are important.
The nurse is preparing to use a stethoscope for auscultation. Which
statement is true regarding the diaphragm of the stethoscope? The
diaphragm: - ANSWER ANS: is used to listen for high-pitched sounds.
The diaphragm of the stethoscope is best for listening to high-pitched
sounds such as breath, bowel, and normal heart sounds. It should be held
firmly against the person's skin, firmly enough to leave a ring. The bell of the
stethoscope is best for soft, low-pitched sounds such as extra heart sounds
or murmurs.
Before auscultating the abdomen for the presence of bowel sounds on a
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