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Chapter 08: Assessment Techniques and Safety in the Clinical Setting Physical Examination and Health Assessment, 8th Edition by Carolyn Jarvis€4,34
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Physical Examination and Health Assessment, 8th Edition by Carolyn Jarvis
MULTIPLE CHOICE
1. When performing a physical assessment, the first technique the nurse will always use is:
a. Palpation.
b. Inspection.
c. Percussion.
d. Auscultation.
ANS: B
The skills requisite for the ph...
Chapter 08: Assessment Techniques and
Safety in the Clinical Setting
Physical Examination and Health Assessment, 8th Edition by
Carolyn Jarvis
MULTIPLE CHOICE
1. When performing a physical assessment, the first technique the nurse will always use is:
a. Palpation.
b. Inspection.
c. Percussion.
d. Auscultation.
ANS: B
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.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. 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.
ANS: B
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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. 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.
ANS: B
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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. 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
ANS: A
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.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. 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.
ANS: D
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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
6. 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
ANS: B
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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion
is to assess the of the underlying tissue.
a. Turgor
b. Texture
c. Density
d. Consistency
ANS: C
Percussion yields a sound that depicts the location, size, and density of the
underlying organ. Turgor and texture are assessed with palpation.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. 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?
a. Percussing once over each area
b. Quickly lifting the striking finger after each stroke
c. Striking with the fingertip, not the finger pad
d. Using the wrist to make the strikes, not the arm
ANS: A
For percussion, the nurse should percuss two times over each location. The
striking finger should be quickly lifted 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 is used to make the strikes, not the arm.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse
should:
a. Consider this a normal finding.
b. Palpate this area for an underlying mass.
c. Reposition the hands, and attempt to percuss in this areaagain.
d. Consider this finding as abnormal, and refer the patient for additional treatment.
ANS: A
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