assessment is the first step in the nursing process, and it is critical that an accurate assessment is obtained in order to diagnose, plan, implement, and evaluate the plan of care. the four basic techniques of the physical examination are : Correct Answer-inspection, palpation, percussion, and aus...
NR 414 exam #1 questions with correct answers
assessment is the first step in the nursing process, and it is critical that an
accurate assessment is obtained in order to diagnose, plan, implement,
and evaluate the plan of care. the four basic techniques of the physical
examination are : Correct Answer-inspection, palpation, percussion, and
auscultation.
inspection has two parts: Correct Answer-general inspection and
systematic inspection
general inspection Correct Answer-observing the patient from front to
back and from each side, checking for symmetry of body parts, obvious
injuries or abnormalities, and overall appearance
systematic inspection Correct Answer-inspecting each body region
systematically from head-to-toe. This is also called a head-to-toe
assessment
guidelines for inspection include: Correct Answer-1. having adequate
lighting—daylight or artificial
2. conducting unhurried and careful inspection
3. exposing what you want to inspect
4. validating findings with patient
5. ensuring appropriate equipment is available
,when conducting the assessment of a new patient, inspection begins with
which step? Correct Answer-general inspection of the patient
which steps are required to conduct accurate inspection? Correct
Answer-1. validate findings with the patient
2. expose the area being inspected
3. ensure adequate lighting is available
what is included as part of the general inspection? Correct Answer-
observing overall appearance of patient
which component is included as part of a systematic inspection? Correct
Answer-inspecting each body region from head to toe
palpitation Correct Answer-involves using the hands and fingers to
gather assessment data through touch. it is used to gather information
about skin temperature, pulsations or vibrations, size of organs, and
tenderness of internal structures.
guidelines for palpation include: Correct Answer-1. keep fingernails
short to avoid hurting the patient.
2. have warm hands and be gentle in approach to assist the patient in
relaxing in order to obtain more accurate data.
3. use correct palpation depth and the appropriate part of the hand to
correctly identify findings without producing unnecessary discomfort to
the patient.
,when assessing the abdomen, always perform __ Correct Answer-
palpation after inspection and auscultation.
gloves should be worn for palpating areas where __ Correct Answer-
contact with body fluids is possible (genitalia or wounds) or when
palpating mucous membranes.
palpitation: palmar surface of the fingers and finger pads Correct
Answer-used to determine position, texture, size, consistency, fluid,
crepitus, form of a mass, or structure
palpitation: ulnar surfaces of hand and fingers Correct Answer-used to
assess vibrations
palpitation: dorsal surface of hand Correct Answer-used to asses
temperature
palpitation: entire hand Correct Answer-used to asses muscle strength
light palpation Correct Answer-accomplished by pressing down to a
depth of approximately 1 cm and is used to assess moisture, texture,
temperature, pulsations, tenderness, and superficial masses and lesions
, deep palpation Correct Answer-accomplished by pressing down to a
depth of 4 cm with one or two hands and is used to determine organ size
and contour, especially of the liver.
bimanual palpation Correct Answer-can be used for light or deep
palpation. bimanual palpation uses both hands to entrap a mass or an
organ (such as the uterus, kidney, or large breasts) between the fingertips
to assess size and shape.
light palpation is best used to obtain which assessment data?
- uterine firmness
- moisture of skin
- liver shape and size
- distention of colon Correct Answer-moisture of skin
bimanual palpation is best used to assess which area of the body?
- liver and large intestine
- female reproductive organs
- pulsations of femoral artery
- skin of the posterior thorax Correct Answer-female reproductive
organs
match the following assessment with the part of the hand best suited to
obtain accurate assessment data. Correct Answer-finger pads = eliciting
reflexes
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