N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide uses open and closed-ended questions. A closed-ended question is the one that requires a discrete answer. For example, the nurse asks, “Where are you having pain?” The patient’s answer will include only those body parts where there is pain. Any question that can be answered by a simple “yes” or “no” is classified as closed-ended question. An open-ended question is the one that requires the patient to explain the answer. For example, the nurse asks, “Describe the pain you are having.” This question will require the patient to give additional information about the pain. Both types of questions are legitimate and the astute nurse will use a combination of closed and open-ended questions during the interview. The interview process may also include interviews with the patient’s family or significant others, if the patient has agreed to share information with others. • The physical exam: During the physical exam, the nurse uses all senses to substantiate information collected in the interviews. This examination uses the techniques of inspection (visual examination of the patient), auscultation (listening to sounds produced by the body), palpation (examination using the sense of touch), and percussion (tapping or striking the body surface to produce sounds or vibrations). One of the major functions performed by the nurse is the physical assessment of the patient. In order to do and document the assessment accurately, the nurse must know some of the common terms associated with any assessment. These terms all relate to the standard anatomical position and the locations associated with this position. In the standard anatomical position, the individual has his feet together (or slightly separated) and the arms are rotated outward so that the palms are forward and the thumbs are pointed away from the body. The arms are usually moved slightly out from the body, so that the hands do not touch the sides. Standard anatomical position:

As the nurse documents a physical assessment, these terms of location must be used so that anyone reading the documentation will have a very clear understanding of the exact location

©2017

Achieve Test Prep

Page 9

of 135