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Terms in this set (38)
Which part of the hand is best suited for palpating vibrations produced during percussion?
Ulnar surface
Which is the rationale behind allowing the preschooler to play with the stethoscope before auscultating breath sounds?
To reduce the child's fear
Which assessment involves tapping the patient's skin with short, sharp strokes?
Percussion
Which type of sounds is auscultated with the bell of the stethoscope?
Low-pitched
The bell of the stethoscope is a concave cup that best transmits low-pitched sounds. The nurse would hold the bell of the stethoscope very lightly on the skin to listen to low-pitched sounds such as heart murmurs. High-pitched sounds such as normal heart sounds can be heard with the diaphragm of the stethoscope. A Doppler ultrasonic stethoscope is used to hear low- and high-amplitude sounds.
Which equipment measures the range of motion of a shoulder joint?
Goniometer
A goniometer is used to measure the angular joint range of motion of the patient.
Which equipment is used to test loss of protective sensation (LOPS) in a patient's foot?
Monofilament
A monofilament is a smooth nylon fiber that is used to assess sensation in the patient's foot and sole.
Under which percussion note characteristic would the nurse document a loud sound perceived during chest percussion?
Amplitude
Which senses would the nurse use while inspecting a patient during a routine physical examination? Select all that apply.
Sight, Smell
Which equipment is used to test the hearing capacity of a patient?
Tuning fork
The nurse may use a tuning fork as part of the clinical assessment to test the auditory capacity and functioning of the patient. High-frequency vibrating tuning forks are placed over the bony prominences of the ear and directly on top of the scalp; an inability to hear the vibrations produced is indicative of hearing loss.
Which position would the nurse instruct a frail older adult patient to assume for the examination process?
Supine
Which instrument is used to examine both the ear and the nose?
Otoscope
Which parts of the ophthalmoscope are present on the front of the ophthalmoscope head? Select all that apply.
Mirror window, Aperture selector
Which is the major task of infancy, according to Erikson's stages of psychosocial development?
Developing a sense of trust
Which assessment skill would the nurse use to determine organ density during the physical examination of a patient?
Percussion
Which part of the hand would the nurse use to assess the skin texture, swelling, and the presence of lumps during palpation?
Fingertips
Arrange the steps of palpation in the correct order during the physical assessment.
1.Washing hands under warm water
2.Placing the patient in a supine position
3.Assessing skin with the use of fingertips
4.Using palmar surface of fingers to feel organs
5.Documenting the confirmed
findings
Arrange the assessments performed by the nurse in a sequential order during the routine physical examination of a patient.
1. Inspection
2.Palpation
3.Percussion
4.Auscultation
Which intervention improves the accuracy of auscultating the lungs of a patient with excessive chest hair?
Moisten the patient's chest hair.
The nurse would wet the patient's chest hair before auscultating the lungs to prevent crackling sounds produced by friction between the stethoscope endpiece and the chest hair.
Which action by the student nurse requires correction?
Palpates the abdomen before listening to the bowel sounds
During an abdominal examination, palpating the abdomen first may interfere with bowel sounds. Therefore the nurse would first listen to the bowel sounds and then palpate the abdomen.
Which percussion note heard over the lung is considered normal in children but abnormal in adults?
Hyperresonant
Percussion notes with loud amplitude, low pitch, and a booming quality that last for a long duration are referred to as hyperresonant percussion notes. Children have a thin chest wall, so a hyperresonant percussion sound is common.
Which findings are obtained during palpation? Select all that apply.
Enlarged organ, Normal arterial pulsations, Presence of muscle spasticity
Palpation is a process of examining the consistency of tissues, alignment and intactness of organs, and symmetry of body parts by using the palms of hands or finger pads.
For which assessments is the palpation technique appropriate? Select all that apply.
1. Identifying the tender areas first and palpating them at the end
2. Starting the assessment with light palpation followed by deep palpation
3. Suggesting that the patient use relaxation techniques during deep palpation
Which type of sound would the nurse expect to hear while percussing the right upper quadrant of the abdomen?
High-pitched, soft sounds occurring for a short time
Which action would the nurse take first to assess a sleeping 4-month-old infant?
Auscultate the lung, heart, and bowel sounds.
Why would the nurse ask the parent to remove a child's gown before auscultating the child's lungs?
To avoid sound artifacts
Which are the requirements for performing proper inspection of a patient during physical examination? Select all that apply.
Good lighting
Ophthalmoscope
Adequate exposure of body parts
Which examination room characteristics are effective? Select all that apply.
Heat source
Tangential lighting
Which sounds would be best heard using the bell endpiece of the stethoscope? Select all that apply.
Heart murmurs
Extra heart sounds
Which intervention is priority when performing an oral assessment on a fussy 3-month-old infant?
Offer brightly colored toys to the child.
Which action by a nurse assessing a 2-month-old child requires correction?
The nurse makes the child sit with support.
Which statement/question by a new nurse assessing a 2-year-old requires correction?
"Can I please listen to your heart now?"
Which intervention would the nurse use when assessing a patient with a respiratory virus to prevent the spread of infection?
The nurse would educate the staff, the patient, and visitors
Which assessment technique would the nurse use to determine the patient's temperature?
Touching the patient's skin with the dorsal side of the hands and fingers
Which patients would the nurse assess using the head-to-toe approach?
an adolescent, an aging adult, and a school-age child.
Which measures would the nurse take while assessing a 3-month-old?
Examine the Moro reflex at the end of the assessment.
Ask the parent to remove the outer clothing of the infant.
Maintain eye contact with the infant throughout the assessment.
Which measures would the nurse take while assessing a patient with a respiratory illness who has severe ear pain?
Ask out about the cause of ear pain in the patient.
Give frequent rest periods to the patient during the examination
Which type of percussion note will the nurse hear while percussing over the scapula?
Flat
Which techniques would the nurse use to assess a 2-year-old patient? Select all that apply.
Compliment the child about clothing and toys.
Allow the child to keep a personal item such as a teddy bear.
Praise when the child cooperates during the various assessment steps.
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