Which techniques will the nurse use to perform a physical examination of a patients skin quizlet?

2

While assessing a patient's rectum and vagina, the nurse should ask the patient to assume Sims' position, not prone position, because this position improves the exposure of rectal area. While assessing a patient's heart, the nurse should ask the patient to assume lateral recumbent position, because this position facilitates easy detection of murmurs. While assessing a patient's abdomen, the nurse should ask the patient to assume dorsal recumbent position, because this position promotes relaxation of abdominal muscles. While assessing a patient's musculoskeletal system, the nurse should ask the patient to assume prone position, because this position provides easy access to the extension of hip joint, skin, and buttocks.

1

While assessing the sensory function of position in the patient, the nurse grasps a finger and holds it by its sides with the thumb and index finger. Then, the nurse alternates moving the finger up and down, asking the patient to state when the finger is up or down. This process is repeated with the toes. The nurse applies the sharp and blunt ends of a paper clip or a broken cotton applicator to the surface of the patient's skin and notes the areas of numbness or increased sensitivity, while assessing the patient's ability to feel pain. The nurse touches the patient's skin with hot and cold test tubes, asking the patient to identify hot or cold sensations, while assessing the patient's ability to sense temperature. The nurse applies the stem of a vibrating fork to the distal interphalangeal joint of the patient's fingers and the interphalangeal joint of the great toe, the elbow, and the wrist, and has the patient voice when and where the patient feels vibration, while assessing the patient's ability to feel vibration.

2

Cranial nerve IX is the glossopharyngeal nerve, which is associated with taste and the ability to swallow. To test the functioning of this nerve, the nurse asks the patient to identify a sour or sweet taste on the back of the tongue, and also uses a tongue blade to elicit the gag reflex. Cranial nerve X is the vagus nerve, which is responsible for the sensation of the pharynx, movement of the vocal cords, and parasympathetic innervation to the glands of mucous membranes. Cranial nerve VII is the facial nerve, which is associated with taste and the ability to swallow. To assess the functioning of this nerve, the nurse has the patient identify a salty or sweet taste on the front of the tongue. Cranial nerve VIII is the auditory nerve, responsible for the sensation of hearing. During the neurological examination, the nurse would assess the patient's ability to hear spoken words.

Inspection is the only technique that is used when assessing every body part and system. Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds. Palpation, percussion and auscultation are not used to assess every body part or system.

The knee-chest position is useful for examining the rectum. In this position, the client kneels on the examination table with the weight of the body supported by the chest and knees. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the dorsal recumbent position, the client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. Areas that may be assessed with the client in this position include the head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses.

Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds.

Sets found in the same folder

When assessing a 73-year-old female patient, the nurse found wrinkles, sagging breasts, and tenting of the skin, gray hair, and thick, brittle toenails. The nurse knows that what normal changes of aging occur that can cause these changes in the integumentary system?

Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails

Decreased extracellular water, surface lipids, and sebaceous gland activity, decreased scalp oil, and decreased circulation

Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply

Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

A 30-year-old patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient's integumentary system?

Warm, flushed skin, alopecia, and thin nails

General hyperpigmentation and loss of body hair

Pale skin, pale mucous membranes, hair loss, and nail dystrophy

Cold, dry, pale skin; dry, coarse hair; and brittle, slow growing nails

Which techniques will the nurse use to perform a physical examination of a patient's skin?

What are the physical examination techniques used in assessing the skin?

Which technique would the nurse use to assess the elasticity of the patients skin quizlet?

What are the 4 techniques used in a physical exam quizlet?