Chapter 08: Assessment Techniques and Safety in the Clinical Setting

Chapter 08: Assessment Techniques and Safety in the Clinical Setting

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

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)                    REF:   p. 115

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 patient’s 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)             REF:   p. 115

MSC:  Client Needs: Safe and Effective Care Environment: Management of Care

 

3. The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patient’s 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)                           REF:   p. 115

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)                    REF:   p. 115

MSC:  Client Needs: Safe and Effective Care Environment: Management of Care

 

5. The nurse is preparing to assess a patient’s 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)                           REF:   p. 115

MSC:  Client Needs: Safe and Effective Care Environment: Management of Care