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Jarvis Ch 8 Assessment Techniques and Safety in the Clinical Setting Exam
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Jarvis Ch 8 Assessment Techniques and Safety in the Clinical Setting Exam
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Jarvis Ch 8 Assessment Techniques andSafety in the Clinical Setting Exam
When performing a physical assessment, the first technique the nurse will always use
is:
a. Palpation.
b. Inspection.
c. Percussion.
d. Auscultation. - Answers -b. 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, 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.
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 patients body systems before proceeding with
palpation. - Answers -b. 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 significantly more than a quick glance.
The nurse is assessing a patients skin during an office visit. What part of the hand and
technique should be used to best assess the patients 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. - Answers -b. Dorsal
surface of the hand; the skin is thinner on this surface than on the palms.
, 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.
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 - Answers -a. 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 patients 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. - Answers -d. The assessment begins with light
palpation to detect surface characteristics and to accustom the patient to being touched.
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.
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 - Answers -b. 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.
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