Health Assessment for Nursing Practice
3G Editorial Board
e-book Edition 2024
Questions & Answers from this book
Questions and answers are connected to the referenced book and its available source material.
Chapter 1: Introduction to Health Assessment
Chapter 2: Physical Examination Techniques
What are the five percussion sounds and what does each indicate?
The five percussion sounds are flatness, dullness, resonance, hyperresonance, and tympany. Flatness, an extremely dull sound, indicates very dense tissue such as muscle or bone. Dullness, a thudlike sound, indicates dense tissue such as the liver, spleen, or heart. Resonance, a hollow sound, indicates air-filled lungs, while hyperresonance, a booming sound heard in emphysematous lungs, is not produced in the normal body. Tympany, a musical or drumlike sound, indicates an air-filled stomach.
Why is the dorsum of the hand used to test skin temperature, and what part of the hand is used to test for vibration?
The dorsum, or back, of the hand and fingers is used to test skin temperature because the examiner's skin there is thinnest. To test for vibration, the nurse should use the palmar surface of the hand.
What are the four primary techniques used in physical examination?
The four primary techniques used in physical examination are inspection, palpation, percussion, and auscultation.
Chapter 4: Mental Health Assessment
When should the nurse auscultate the thyroid gland, and what technique is used?
Auscultate the thyroid gland only when inspection or palpation reveals an enlarged thyroid. Place the bell of the stethoscope over the lateral lobes of the gland and ask the client to hold his breath during auscultation so tracheal breath sounds do not obscure the assessment.
What does the COLDSPA mnemonic stand for and how is it used in symptom assessment?
COLDSPA stands for Character, Onset, Location, Duration, Severity, Pattern, and Associated Factors (sometimes listed as Patterns). It is used as a memory aid to explore each symptom a client reports by asking structured questions about its features, timing, location, duration, severity, aggravating and relieving factors, and accompanying effects.
What are the five types of sounds elicited by percussion, and what does each indicate about the underlying tissue?
The five percussion sounds are flatness, dullness, resonance, hyperresonance, and tympany. Flatness indicates very dense tissue such as muscle or bone; dullness indicates dense tissue such as the liver, spleen, or heart. Resonance indicates air-filled tissue such as normal lungs, hyperresonance is a booming sound associated with emphysematous lungs, and tympany indicates an air-filled stomach. Flatness reflects the most dense tissue with the least air, and tympany reflects the least dense tissue with the greatest amount of air.
Chapter 5: Assessment of Vital Signs and Body Measurements
What does the mnemonic SOCRATES stand for in pain history taking?
SOCRATES is a mnemonic for taking a pain history: Site, Onset, Character, Radiation, Associations, Timing, Exacerbating and relieving factors, and Severity. Each of these elements should be documented in the history of the presenting complaint.
What are the eight questions to ask about each symptom during a cardiovascular history?
The eight questions to ask about each cardiovascular symptom, as given for any symptom in the history, are onset, duration, course, severity, precipitating factors, relieving factors, associated features, and previous episodes.
How is the quality of a sound described during auscultation?
Quality is described subjectively, using terms such as whistling, gurgling, or snapping, to characterize the nature of the sound heard during auscultation.
Chapter 6: Assessment of Skin, Hair, and Nails
Why is the external jugular vein not routinely used to assess the JVP?
The external jugular vein is not routinely used to assess the JVP because, although it is superficial and easily visualized, it is prone to kinking, which can give misleading results. The internal jugular vein is preferred because its pulsation reflects right atrial pressure more reliably.
What is the normal capillary refill time, and how is it assessed?
Normal capillary refill time is less than 2 seconds. It is assessed by pressing the end of the patient's finger for 5 seconds, releasing, and observing how long it takes for the color to return.
What does the acronym S.O.B.E.R. stand for in the S.O.B.E.R. Stress Interruption Technique?
In the S.O.B.E.R. Stress Interruption Technique, S.O.B.E.R. stands for Stop, Observe, Breathe, Expand awareness, and Respond with awareness.
Chapter 7: Assessment of Cardiovascular and Respiratory Systems
What are the waist circumference thresholds indicating increased and substantially increased risk for metabolic complications in men and women?
For women, increased risk is a waist circumference of at least 80 cm (32 in), and substantially increased risk is at least 88 cm (35 in). For men, increased risk is at least 94 cm (37 in), and substantially increased risk is at least 102 cm (40 in).
What is the normal range for oxygen saturation in adults according to the chapter?
The normal range for oxygen saturation in adults is 96% to 100%, according to the chapter's review questions and answer key.
Chapter 8: Assessment of Gastrointestinal, Genitourinary, and Musculoskeletal Systems
What is the difference between guarding and rigidity during abdominal palpation?
Guarding is a voluntary contraction of the abdominal wall muscles, often due to fear, anxiety, or cold hands, while rigidity is an involuntary contraction triggered by peritoneal inflammation and cannot be controlled by the patient.
Why is auscultation of the abdomen performed before percussion and palpation, and where should the examiner begin listening for bowel sounds?
Auscultation of the abdomen follows inspection because listening immediately after inspection provides a more accurate assessment of bowel sounds, before the effects of percussion and palpation. The examiner should begin in the right lower quadrant (RLQ), because bowel sounds are consistently heard there, and then move clockwise through the other quadrants.
How does osteoarthritis differ from rheumatoid arthritis in terms of underlying cause and pathophysiology?
Osteoarthritis is caused by aging and mechanical wear and tear on articular cartilage, leading to cartilage thinning, bone thickening, and joint swelling. Rheumatoid arthritis is an autoimmune disease in which the immune system attacks the body's own tissues, causing inflammation of the joint capsule and synovial membrane and eventual cartilage damage.
You may also be interested in
Anatomy Physiology by Elaine N. Marieb, Katja N. Hoehn
Elaine N. Marieb and Katja Hoehn
60 questions
Middle Range Theory for Nursing
Mary Jane Smith, PhD, RN, FAAN,Patricia R. Liehr, PhD, RN
40 questions
Oxford Handbook of Adult Nursing, Third Edition
Unknown
37 questions
Fundamentals of Pharmacology: An Applied Approach for Nursing and Health
Alan Galbraith ... [et Al.].
36 questions