NURS 123 All Quizzes Solved Fully With Verified 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 Palpationcorrect answer 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 Supinecorrect answer 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 headcorrect answer 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 recumbentcorrect answer 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: -Teach patients about better health promotion -Help select the best nursing measures -Compare the patient's status with previous findings -Help the nurse gather additional datacorrect answer Compare the patient's status with previous findings In acute care settings, you perform a brief physical assessment at the beginning of each shift to identify changes in the patient's status for comparison with the previous assessment. After gathering data, the nurse groups significant findings into patterns of data that reveal actual or risk nursing diagnoses. Each abnormal finding directs the nurse to gather additional data. The information is useful in selecting the best nursing measures to manage the patient's health problems. During the physical assessment is an ideal time to offer patient teaching and encourage promotion of health practices, such as breast (Box 6-1) and genital (Box 6-2) self-examination. When performing an assessment of the cardiovascular system, the nurse evaluates the skin and nails of the patient. Inadequate tissue perfusion is known as edema infiltration ischemia infarctioncorrect answer ischemia Inadequate tissue perfusion results in inadequate delivery of oxygen and nutrients to cells, a condition called ischemia. This is caused by constriction of vessels or by occlusion (blockage) from clot formation. An increased amount of deoxygenated hemoglobin may cause a change in skin color known as cyanosis Homan's sign Raynaud's phenomenon infarctioncorrect answer cyanosis Bluish (cyanosis) coloring of the skin is caused by an increased amount of deoxygenated hemoglobin (associated with hypoxia). An elderly patient is admitted to the hospital after a fall. Initial assessment of the patient does not need to include assessment of the cranial nerves. True Falsecorrect answer False Patient may have fallen d/t an unknown/undiagnosed neuro problem (stroke, tia, dementia) and baseline cranial nerve check is a good idea It is not necessary to perform a skin assessment on