Nur 245 Exam II |277 Questions and Answers
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.
-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.
-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.
-. 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.
-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.
-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.
-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.
-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
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.
-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.
-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.
-. 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.
-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.
-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.
-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.
-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
