NURS 212 Midterm Questions With Complete Solutions
4 assessment techniques
Inspection
Palpation
Percussion
Auscultation
Inspection
concentrated watching
Palpation
Applying sense of touch to assess texture, temperature,
moisture, organ location and size, swelling, vibration or
pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses, and presence of tenderness and pain
Palpation techniques
Fingertips: used for texture, swelling, pulsation, determining
presence of lumps
Grasping of fingers and thumb: used to detect position, shape,
and consistency of organ or mass
Back of hands: used for assessing temperature
Back of fingers or ulnar surface of hand: used for vibration
types of palpation
,light
deep
superficial
bimanual
vibration
Inspection with palpation
1. uniformity of appearance
2. thickness
3. symmetry
4. hygiene
5. integrity
6. temperature
7. usual color
8. detecting color changes in light and dark skin
9. capillary refill
10. moisture
11. turgor
12. lesions
Color changes with Anemia and Shock (pallor)
Anemia: decreased hematocrit
Shock: decreased perfusion, vasoconstriction
Light skin: generalized pallor
Dark skin: brown skin appears yellow-brown, dull; black skin
appears ash gray, dull; skin loses its healthy glow - check areas
with least pigmentation such as conjunctivae, mucous
membranes
Color changes with local artery insufficiency (pallor)
,light skin: marked localized pallor (lower extremities esp when
elevated)
dark skin: ash gray, dull; cool to palpation
Color changes with albinism (pallor)
light skin: whitish pink
dark skin: tan, cream, white
color changes with Vitiligo (pallor)
Patchy depigmentation from destruction of melanocytes
light and dark skin: patchy milky-white spots, often symmetric
bilaterally
Color changes with increased amount of unoxygenated
hemoglobin (cyanosis)
Central: chronic heart and lung disease cause arterial
desaturation
Light skin: dusky blue
Dark skin: dark but dull, lifeless; only severe cyanosis is
apparent in skin - check conjunctivae, oral mucosa, nail beds
Peripheral: exposure to cold, anxiety
Light skin: nail beds dusky
Color changes with hyperemia (erythema)
Increased blood in engorged arterioles (inflammation, fever,
alcohol intake, blushing)
, Light skin: red, bright pink
Dark skin: purplish tinge, palpate for increased warmth with
inflammation, taut skin, and hardening of deep tissues
Color changes with Polycythemia (erythema)
Increased RBCs, capillary stasis
Light skin: ruddy blue in face, oral mucosa, conjunctiva, hands,
and feet
Dark skin: well concealed by pigment, check for redness in lips
Color changes with carbon monoxide poisoning (erythema)
Light skin: bright cherry red in face and upper torso
Dark skin: cherry-red color in nail beds, lips, and oral mucosa
Color changes with Venous stasis (erythema)
Decreased bloodflow from area, engorged venules
Light skin: dusky rubor of dependent extremities; a prelude to
necrosis with pressure sore
Dark skin: easily masked, use with palpation for warmth or
edema
4 assessment techniques
Inspection
Palpation
Percussion
Auscultation
Inspection
concentrated watching
Palpation
Applying sense of touch to assess texture, temperature,
moisture, organ location and size, swelling, vibration or
pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses, and presence of tenderness and pain
Palpation techniques
Fingertips: used for texture, swelling, pulsation, determining
presence of lumps
Grasping of fingers and thumb: used to detect position, shape,
and consistency of organ or mass
Back of hands: used for assessing temperature
Back of fingers or ulnar surface of hand: used for vibration
types of palpation
,light
deep
superficial
bimanual
vibration
Inspection with palpation
1. uniformity of appearance
2. thickness
3. symmetry
4. hygiene
5. integrity
6. temperature
7. usual color
8. detecting color changes in light and dark skin
9. capillary refill
10. moisture
11. turgor
12. lesions
Color changes with Anemia and Shock (pallor)
Anemia: decreased hematocrit
Shock: decreased perfusion, vasoconstriction
Light skin: generalized pallor
Dark skin: brown skin appears yellow-brown, dull; black skin
appears ash gray, dull; skin loses its healthy glow - check areas
with least pigmentation such as conjunctivae, mucous
membranes
Color changes with local artery insufficiency (pallor)
,light skin: marked localized pallor (lower extremities esp when
elevated)
dark skin: ash gray, dull; cool to palpation
Color changes with albinism (pallor)
light skin: whitish pink
dark skin: tan, cream, white
color changes with Vitiligo (pallor)
Patchy depigmentation from destruction of melanocytes
light and dark skin: patchy milky-white spots, often symmetric
bilaterally
Color changes with increased amount of unoxygenated
hemoglobin (cyanosis)
Central: chronic heart and lung disease cause arterial
desaturation
Light skin: dusky blue
Dark skin: dark but dull, lifeless; only severe cyanosis is
apparent in skin - check conjunctivae, oral mucosa, nail beds
Peripheral: exposure to cold, anxiety
Light skin: nail beds dusky
Color changes with hyperemia (erythema)
Increased blood in engorged arterioles (inflammation, fever,
alcohol intake, blushing)
, Light skin: red, bright pink
Dark skin: purplish tinge, palpate for increased warmth with
inflammation, taut skin, and hardening of deep tissues
Color changes with Polycythemia (erythema)
Increased RBCs, capillary stasis
Light skin: ruddy blue in face, oral mucosa, conjunctiva, hands,
and feet
Dark skin: well concealed by pigment, check for redness in lips
Color changes with carbon monoxide poisoning (erythema)
Light skin: bright cherry red in face and upper torso
Dark skin: cherry-red color in nail beds, lips, and oral mucosa
Color changes with Venous stasis (erythema)
Decreased bloodflow from area, engorged venules
Light skin: dusky rubor of dependent extremities; a prelude to
necrosis with pressure sore
Dark skin: easily masked, use with palpation for warmth or
edema
