Perry: Clinical Nursing Skills & Techniques, 8th Edition
Chapter 6: Health Assessment
Test Bank
MULTIPLE CHOICE
1. The nurse is visiting the patient for the first time this shift. She introduces herself
and asks the
...
Perry: Clinical Nursing Skills & Techniques, 8th Edition
Chapter 6: Health Assessment
Test Bank
MULTIPLE CHOICE
1. The nurse is visiting the patient for the first time this shift. She introduces herself
and asks the patient several questions related to his condition. While doing so, and
without being obvious, she is looking at the color of his eyes and is assessing his ears and
nose for discharge and the symmetry of his mouth. The nurse is using the assessment
technique known as:
a. Palpation
b. Percussion
c. Inspection
d. Auscultation
Inspection is the visual examination of body parts or areas. An experienced nurse learns
to make multiple observations, almost simultaneously, while becoming very perceptive of
abnormalities.
Palpation uses the sense of touch. Percussion involves tapping the body with the
fingertips to evaluate the size, borders, and consistency of body organs and to discover
fluid in body cavities. Auscultation is listening with a stethoscope to sounds produced by
the body.
DIF: Cognitive Level: Application REF: Text Reference: Page 108
OBJ: Describe the techniques used with each assessment skill. TOP: Inspection
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The patient is admitted with fever and acute lower abdominal pain. He has taken
Tylenol but says he still feels feverish. Before taking the patient’s temperature, the nurse
may:
a. Touch the patient’s skin with the dorsum of her hand
b. Touch the patient’s skin with the pads of her fingers
c. Palpate the skin using the bimanual method
d. Tap the patient’s skin using the fingertips
The dorsum (back) of the hand is more sensitive to temperature variations.
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The pads of the fingertips detect subtle changes in texture, shape, size, consistency, and
pulsation of body parts. Bimanual palpation involves one hand placed over the other
while pressure is applied. The upper hand exerts downward pressure as the other hand
feels the subtle characteristics of underlying organs and masses. Seek the assistance of a
qualified instructor before attempting deep palpation. Percussion involves tapping the
body with the fingertips to evaluate the size, borders, and consistency of body organs and
to discover fluid in body cavities.
DIF: Cognitive Level: Application REF: Text Reference: Page 109
OBJ: Describe the techniques used with each assessment skill. TOP: Palpation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. The assessment technique that involves striking the body surface directly with one
of two fingers is known as:
a. Indirect percussion
b. Deep palpation
c. Direct percussion
d. Light palpation
Two methods of percussion are direct and indirect. The direct method involves striking
the body surface directly with one or two fingers.
Perform the indirect technique by placing the middle finger of your nondominant hand
firmly against the body surface. With palm and fingers remaining off the skin, the tip of
the middle finger of the dominant hand strikes the base of the distal joint of the finger.
After light palpation, use deeper palpation to examine the condition of organs. Depress
the area you are examining by approximately 2 cm (1 inch). For light palpation, apply
pressure slowly, gently, and deliberately, depressing about 1 cm (½ inch).
DIF: Cognitive Level: Application REF: Text Reference: Page 111
OBJ: Describe the techniques used with each assessment skill. TOP: Percussion
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. When preparing to complete an assessment for a 16-year-old patient, a nurse
should:
a. Focus on illness behaviors
b. Plan for a diminished energy level
c. Treat the patient as an individual
d. Have the parents present throughout
Older children and adolescents tend to respond best when treated as adults and
individuals and often can provide details about their health history and severity of
symptoms
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