The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. Which proper sequence will the nurse follow to perform the initial assessment?
a. Light palpation, deep palpation, and inspection
b. Inspection, light palpation, and deep palpation
c. Auscultation and light palpation
d. Inspection and light palpation
ANS: D
Inspection is the use of vision and hearing to distinguish normal from abnormal findings. Light palpation determines areas of tenderness and skin temperature, moisture, and texture. Deep palpation is used to examine the condition of organs, such as those in the abdomen. Caution is the rule with deep palpation. Deep palpation is performed after light palpation; however, deep palpation is not performed on a fractured leg. Auscultation is used to evaluate sound and is not used to assess a fractured leg.
You might also like to view...
Herbs and plants can be useful in treating a variety of conditions. Which treatment should a nurse determine is appropriate for a client experiencing frequent migraine headaches?
1. Saint John's wort combined with an antidepressant 2. Ginger root combined with a beta-blocker 3. Feverfew, used according to directions 4. Kava-kava added to a regular diet
A nurse is examining a client with cirrhosis of the liver and notes the presence of edema. The nurse determines that the indentation remains for several seconds and the skin swelling is obvious on inspection
How should the nurse quantify the severity of the finding? A) 1+ pitting edema B) 2+ pitting edema C) 3+ pitting edema D) 5+ brawny edema
A child with a severe nut allergy has just been brought to the emergency department (ED) in apparent anaphylaxis after accidentally eating peanut butter. What action should the ED nurse prioritize in the care of this patient?
A) Obtain a full set of vital signs. B) Take measures to relieve the boy's anxiety. C) Applying supplementary oxygen by simple face mask. D) Protect the boy's airway.
Which of the following statements regarding hepatitis A virus infection (HAV) is INCORRECT?
A. It is transmitted by fecal contamination of food or water supplies. B. Recovery confers immunity to subsequent HAV infection. C. HAV infection becomes chronic in many infected persons who become chronic carriers of the virus and may develop chronic hepatitis. D. It may be transmitted by anal-to-oral and/or oral-to-genital sexual practices.