Exam (elaborations)
Nurs 123 All Quizzes Detailed Questions And Expert Answers
- Course
- NURSING 123
- Institution
- University Of Michigan
Nurs 123 All Quizzes Detailed Questions And Expert Answers
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Nurs 123 All Quizzes Detailed Questions AndExpert Answers
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. The nurse is using the
assessment technique known as:
Auscultation
Percussion
Inspection
Palpation - ANS Inspection
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.
The nurse is preparing to examine a patient who has chronic lung disease. She
realizes that the patient most likely will need to be in which position for the
examination?
,Sitting upright (Fowler's)
Side-lying
Prone
Supine - ANS Sitting upright (Fowler's)
Position patient sitting upright. This promotes full lung expansion during
examination. Patients with chronic respiratory disease will likely need to sit up
throughout the examination because of shortness of breath. Only if the patient is
unable to tolerate sitting would a supine position or a side-lying position be used.
Which technique is most appropriate for a nurse to implement during the
assessment of the abdomen?
-Palpating painful areas first
-Palpating painful masses or organ enlargement deeply and firmly
-Auscultating for 5 minutes over each quadrant or until bowel sounds are heard
-Positioning the patient in a supine position with the arms behind or over the
head - ANS Auscultating for 5 minutes over each quadrant or until bowel sounds
are heard
To auscultate bowel sounds, place the diaphragm of the stethoscope lightly over
each of the four abdominal quadrants. Listen 5 minutes over each quadrant before
deciding that bowel sounds are absent.
, Painful areas are assessed last. Manipulation of a body part can increase the
patient's pain and anxiety and make the remainder of assessment difficult to
complete. Placing the arms under the head or keeping the knees fully extended
can cause the abdominal muscles to tighten. Tightening of muscles prevents
adequate palpation. If masses are palpated, note size, location, shape, consistency,
tenderness, mobility, and texture. Manipulation of a body part can increase the
patient's pain and anxiety and can make the remainder of assessment difficult to
complete.
Which patient position maximizes the nurse's ability to assess the patient's body
for symmetry?
Supine in bed
Sitting on the side of the bed
Prone in bed
Dorsal recumbent - ANS Sitting on the side of the bed
Sitting upright provides full expansion of lungs and allows better visualization of
symmetry of upper body parts.
The supine position maximizes the nurse's ability to assess pulse sites. The prone
position is used only to assess extension of the hip joint. The dorsal recumbent
position is used for abdominal assessment because it promotes relaxation of
abdominal muscles
The purpose of the physical assessment is to:
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