g.Percussion hammer: Instrument with a rubber
head, used to test reflexes and determine tissue
density- a.patient’s age
b.patient’s physical condition
c. patient’s energy level
d.need for privacy - a.Patient: Consider physiologic and psychological
needs of the patient. Explain that a physical
assessment will be done by the nurse, that body
structures will be examined, and that such
assessments are painless. Have patient put on
a gown and empty bladder.
b.Environment: The time of the assessment
should be mutually agreed on and should not
interfere with meals or daily routines. The
patient should be as free of pain as possible,
and the room should be quiet and private.
5.See table below.
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:ANSWER KEY 367
Technique Definition Assessment/Observationa.Inspection: Process of deliberate, purposeful Body size, color, shape, position,
observations performed in a symmetry, norms, and deviations
systematic manner. from norm.b.Palpation: Technique that uses sense of touch. Temperature, turgor, texture,
moisture, vibrations, shape.c.Percussion: The act of striking an object against Location, shape, size, and density
another object to produce a sound. of tissues.d.Auscultation: The act of listening to sound Lung and bowel sounds; heart and
produced in the body, using vascular sounds.
stethoscope.- a.Pitch—ranging from high to low
b.Loudness—ranging from soft to loud
c. Quality—for example, swishing or gurgling
d.Duration—short, medium, or long - a.Edema: Palpate edematous area with the fingers;
an indentation may remain after the pressure is
released.
b.Dehydration: Pick up the skin in a fold; when
dehydration exists, normal elasticity and
fullness are decreased, and skin fold returns
to normal slowly. - a.Reaction to light: Ask patient to look straight
ahead, bring the penlight from side of patient’s
face, and shine the light on one of the pupils.
Observe pupil’s reaction; normally it will
constrict. Repeat procedure in the same eye,
and observe the other eye—normally it too will
constrict. Repeat the entire procedure with the
other eye.
b.Accommodation: Hold the forefinger about 10
to 15 cm in front of the bridge of the patient’s
nose. Ask the patient to first look at the forefin-
ger, then at a distant object, then the forefinger
again. Normally, the pupil constricts when the
patient looks at the finger and dilates when
he/she looks at a distant object.
c. Convergence: Move a finger toward the patient’s
nose. Normally, the patient’s eyes converge.- a.Weber: Hold the tuning fork at its base and strike
it against the palm of the opposite hand so that
the fork vibrates. Place the base of the fork on
the center of the top of the patient’s head; ask
patient where the sound is heard. Normal find-
ings: sound is heard in both ears or in midline.
SHORT ANSWER
- a.Establish a nurse–patient relationship
b.Gather data about the patient’s general health
status, integrating physiologic, psychological,
cognitive, sociocultural, developmental, and
spiritual dimensions.
c. Identify patient strengths.
d.Identify existing and potential health problems.
e.Establish a base for the nursing process. - a.Ophthalmoscope: Lighted instrument used for
visualization of interior structures of the eye
b.Otoscope: Lighted instrument used for examin-
ing external ear canal and tympanic membrane
c. Snellen chart: Screening test for vision
d.Nasal speculum: Instrument that allows visualiza-
tion of lower and middle turbinates of the nose
e.Vaginal speculum: Two-bladed instrument used
to examine vaginal canal and cervix
f. Tuning fork: Two-pronged metal instrument
used for testing auditory function and vibratory
perception
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