Chapter 09 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 09 Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 2

Type: MCSA

The nurse is preparing to assess the sinuses of an adult client using direct percussion. Which technique is the most appropriate for this assessment?

1. Using the hyperextended middle finger of the nondominant hand.
2. Using the closed fist of dominant hand.
3. Using the palm of the nondominant hand.
4. Using the fingertips of the dominant hand.

Correct Answer: 4

Rationale 1: Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor.

Rationale 2: Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand.

Rationale 3: The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion.

Rationale 4: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess thorax of an infant and also to assess the sinuses of an adult client.

Global Rationale: Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess the thorax of an infant and also to assess the sinuses of an adult client. Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor. Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand. The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: p. 147

 

Question 3

Type: MCSA

During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which action by the nurse is the most appropriate?

1. Document this as abnormal.
2. Wet the chest hair before auscultating the chest.
3. Place the diaphragm on top of the client’s shirt.
4. Switch from the diaphragm to the bell.

Correct Answer: 2

Rationale 1: The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal.

Rationale 2: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the client’s chest before auscultation.

Rationale 3: Auscultating lung sounds over the client’s clothing will increase rather than decrease friction sounds.

Rationale 4: Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them won’t make a difference.

Global Rationale: Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should wet the hair on the client’s chest before auscultation. The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal. Auscultation of lung sounds over the client’s clothing will increase rather than decrease friction sounds. Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them won’t make a difference.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 148–149

 

Question 4

Type: MCSA

The nurse educator is observing a student nurse who is performing cervical palpation on an adult client. Which technique is appropriate for this assessment?

1. Downward pressure of 1–2 cm using the finger pads.
2. Side to side pressure of ½–1 cm using the finger pads.
3. Downward pressure of 2–4 cm using the palmar surface of the fingers
4. Light pressure using the base of the fingers (metacarpophalangeal joints).

Correct Answer: 2

Rationale 1: Downward depression of 1–2 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen.

Rationale 2: Side-to-side palpation of ½–1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node).

Rationale 3: Deep palpation of 2–4 cm (3/4–1½ in.) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward.

Rationale 4: Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus.

Global Rationale: Side-to-side palpation of ½–1 cm in depth will not be sufficient to examine structures that lie deep within a body cavity or those that are covered with thick muscle. This may be sufficient to determine the size and consistency of a finding in the soft tissue (such as a cervical lymph node). Downward depression of 1–2 cm using the finger pads is not sufficient depth to assess structures that lie deep within the abdominal cavity. This describes moderate palpation, used for most of the structures of the body, but not the kidney or spleen. Deep palpation of 2–4 cm (3/4–1½ in.) is used to palpate an organ lying deep within a body cavity such as the spleen or the kidneys. This is done by placing the palmar surface of the fingers of the dominant hand on the skin surface with the extended fingers of the nondominant hand covering and guiding the fingers downward. Light pressure using the base of the fingers or metacarpophalangeal joints is the technique used in the assessment for vibratory tremors, or fremitus.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment.

MNL Learning Outcome: 2.2. Techniques of Physical Assessment

Page Number: pp. 145–147