Podcast
Questions and Answers
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?
- Lung sounds
- High pitched sounds
- Low pitched sounds (correct)
- Normal heart sounds
In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?
In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?
Inspection, palpation, percussion, auscultation
During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?
During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?
- Palpation (correct)
- Percussion
- Auscultation
- Inspection
Palpation is a necessary skill in nursing. Which structures would be included in assessment by palpation?
Palpation is a necessary skill in nursing. Which structures would be included in assessment by palpation?
The nurse detects gurgling throughout the abdomen. This indicates ________.
The nurse detects gurgling throughout the abdomen. This indicates ________.
A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?
A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?
While performing the physical examination of a client, a nurse lightly taps certain parts of the body. What is the purpose of this method of assessment?
While performing the physical examination of a client, a nurse lightly taps certain parts of the body. What is the purpose of this method of assessment?
Which piece of equipment should the nurse use to view the ear canal and tympanic membrane?
Which piece of equipment should the nurse use to view the ear canal and tympanic membrane?
Which position should the nurse place the client in for a genital examination?
Which position should the nurse place the client in for a genital examination?
What is used to gauge central and peripheral nervous system disorders?
What is used to gauge central and peripheral nervous system disorders?
What should a nurse do before auscultating bowel sounds?
What should a nurse do before auscultating bowel sounds?
Which preparation by the nurse is of greatest priority for the physical examination of a client with scabies?
Which preparation by the nurse is of greatest priority for the physical examination of a client with scabies?
What is the nurse's best action to ensure she can hear bowel sounds during an examination of the abdomen?
What is the nurse's best action to ensure she can hear bowel sounds during an examination of the abdomen?
Place in order the areas the nurse will assess when completing a physical examination of a client who is lying down.
Place in order the areas the nurse will assess when completing a physical examination of a client who is lying down.
Which of the following can the nurse most effectively assess with the client in a standing position?
Which of the following can the nurse most effectively assess with the client in a standing position?
Which illustrates the nurse using the technique of inspection?
Which illustrates the nurse using the technique of inspection?
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Study Notes
Objective Data Collection: Physical Examination
- Bell of the stethoscope is utilized to auscultate low-pitched sounds such as heart murmurs and bruits.
- Four physical assessment techniques in order: inspection, palpation, percussion, and auscultation; inspection prevents distraction from altered structures.
Techniques for Physical Assessment
- Palpation is employed to assess the size of internal structures such as the liver.
- Structures assessable via palpation include the thyroid gland.
- To check for fever in a child, use the dorsal surface of the hand for temperature assessment.
Assessment Methods
- Percussion helps determine if a structure is filled with air, fluid, or solid by producing sound waves.
- An otoscope is necessary for examining the ear canal and tympanic membrane.
Client Positioning and Nervous System Assessment
- Female clients should be positioned in lithotomy for genital examinations.
- Reflex strength is a gauge for assessing central and peripheral nervous system disorders.
Hygiene and Preparation
- Disinfect the stethoscope prior to auscultating bowel sounds to ensure hygiene.
- For a client with scabies, adequate lighting is critical to properly examine the skin, with sunlight being preferred.
Environmental Considerations
- Reduce environmental noise to enhance the ability to hear bowel sounds during an abdominal examination.
- In a lying position, assess in the following order: breasts, chest and thorax, cardiovascular, groin, hips, knees, and finally shins and ankles.
Assessing Balance and Observation Techniques
- Assess balance effectively when the client is in a standing position.
- The technique of inspection is demonstrated by detecting odors, such as a fruity smell from the patient's breath.
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